Provider Demographics
NPI:1255463568
Name:RUSSELL, JON (RPH)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:
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 1:477 STRAWBERRY LN
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-1559
Mailing Address - Country:US
Mailing Address - Phone:570-403-7785
Mailing Address - Fax:
Practice Address - Street 1:1 E BROAD ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-6520
Practice Address - Country:US
Practice Address - Phone:570-454-2476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP039898L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist