Provider Demographics
NPI:1023443199
Name:BLENIS, RUSSELL GORDON (PHARMD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:GORDON
Last Name:BLENIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2583 S VOLUSIA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-9129
Mailing Address - Country:US
Mailing Address - Phone:386-774-5800
Mailing Address - Fax:
Practice Address - Street 1:2583 S VOLUSIA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-9129
Practice Address - Country:US
Practice Address - Phone:386-774-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS43617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist