Provider Demographics
NPI:1952318875
Name:RUSSELL, GREGG ALAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:GREGG
Middle Name:ALAN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:MI
Mailing Address - Zip Code:49245-1046
Mailing Address - Country:US
Mailing Address - Phone:517-568-3400
Mailing Address - Fax:517-568-5608
Practice Address - Street 1:126 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:MI
Practice Address - Zip Code:49245-1046
Practice Address - Country:US
Practice Address - Phone:517-568-3400
Practice Address - Fax:517-568-5608
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302031145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist