Provider Demographics
NPI:1295324572
Name:RUSSELL, MICHAEL C
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:C
Last Name:RUSSELL
Suffix:
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 1:1330 US 41 W
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-3152
Mailing Address - Country:US
Mailing Address - Phone:906-250-7034
Mailing Address - Fax:906-485-4482
Practice Address - Street 1:1330 US 41 W
Practice Address - Street 2:
Practice Address - City:ISHPEMING
Practice Address - State:MI
Practice Address - Zip Code:49849-3152
Practice Address - Country:US
Practice Address - Phone:906-250-7034
Practice Address - Fax:906-485-4482
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist