Provider Demographics
NPI:1184946477
Name:RUSSO, JOSEPH I
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:RUSSO
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 CURTISS CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-4315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:741 E LITTLE CREEK RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518-3709
Practice Address - Country:US
Practice Address - Phone:757-480-2888
Practice Address - Fax:757-480-2446
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-27
Last Update Date:2010-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202004300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist