Provider Demographics
NPI:1467126557
Name:RUSSELL, BRIAN SCOTT (BS, RPH, DPH, BCMTMS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:SCOTT
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:BS, RPH, DPH, BCMTMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12709 TAYMAN FARM RD
Mailing Address - Street 2:
Mailing Address - City:BRANDYWINE
Mailing Address - State:MD
Mailing Address - Zip Code:20613-2406
Mailing Address - Country:US
Mailing Address - Phone:405-417-1604
Mailing Address - Fax:
Practice Address - Street 1:12709 TAYMAN FARM RD
Practice Address - Street 2:
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-2406
Practice Address - Country:US
Practice Address - Phone:405-417-1604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12718183500000X
FLPS47447183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist