Provider Demographics
NPI:1649509498
Name:RUSSELL, LISA MARIE (RPH)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 S. WHEELER ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951
Mailing Address - Country:US
Mailing Address - Phone:498-381-8396
Mailing Address - Fax:409-384-7480
Practice Address - Street 1:1250 S WHEELER ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-5120
Practice Address - Country:US
Practice Address - Phone:498-381-8396
Practice Address - Fax:409-384-7480
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30278183500000X
IL051-290906183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist