Provider Demographics
NPI:1932700424
Name:RUSSELL, CHANDRA NICHOLE
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:NICHOLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 N 7TH ST APT 4121
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-2874
Mailing Address - Country:US
Mailing Address - Phone:918-606-8286
Mailing Address - Fax:
Practice Address - Street 1:3116 S GARNETT RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-1933
Practice Address - Country:US
Practice Address - Phone:918-622-7923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PW18136183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist