Provider Demographics
NPI:1265087423
Name:RUSSELL, GARRETH GLEN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:GARRETH
Middle Name:GLEN
Last Name:RUSSELL
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 1:1550 MOORES LN STE B
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-4657
Mailing Address - Country:US
Mailing Address - Phone:903-792-7435
Mailing Address - Fax:903-793-0485
Practice Address - Street 1:1550 MOORES LN STE B
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-4657
Practice Address - Country:US
Practice Address - Phone:903-792-7435
Practice Address - Fax:903-793-0485
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX59876183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist