Provider Demographics
NPI:1205825478
Name:RUSSELL, JAY C (RPH)
Entity type:Individual
Prefix:MR
First Name:JAY
Middle Name:C
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 1:3747 POE RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-9791
Mailing Address - Country:US
Mailing Address - Phone:330-722-3713
Mailing Address - Fax:
Practice Address - Street 1:175 GREAT OAKS TRL
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-8712
Practice Address - Country:US
Practice Address - Phone:330-336-3588
Practice Address - Fax:330-336-5479
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-3-09809183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist