Provider Demographics
NPI:1396320081
Name:RUSSELL, TERESA LYN (CPHT)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:LYN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5825 BROCKWAY RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48638-4522
Mailing Address - Country:US
Mailing Address - Phone:989-497-8112
Mailing Address - Fax:989-497-8114
Practice Address - Street 1:5825 BROCKWAY RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48638-4522
Practice Address - Country:US
Practice Address - Phone:989-497-8112
Practice Address - Fax:989-497-8114
Is Sole Proprietor?:No
Enumeration Date:2021-03-14
Last Update Date:2021-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303003722183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician