Provider Demographics
NPI:1720502297
Name:RUSSELL, DYLAN (PHARMD, RPH)
Entity Type:Individual
Prefix:MS
First Name:DYLAN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 CARDINAL WAY
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-2782
Mailing Address - Country:US
Mailing Address - Phone:207-852-6632
Mailing Address - Fax:
Practice Address - Street 1:915 UNION ST STE 7
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-8604
Practice Address - Country:US
Practice Address - Phone:207-973-6788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR69366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist