Provider Demographics
NPI:1245465467
Name:RUSSELL, RYAN MICHAEL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MICHAEL
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2911 RUSSELL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1536
Mailing Address - Country:US
Mailing Address - Phone:314-771-3269
Mailing Address - Fax:314-344-6179
Practice Address - Street 1:12266 DE PAUL DR
Practice Address - Street 2:SUITE 105
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2514
Practice Address - Country:US
Practice Address - Phone:314-344-7300
Practice Address - Fax:314-344-7179
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006024046183500000X
IL051287298183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO606172302Medicaid