Provider Demographics
NPI:1881066181
Name:TETT, RUSSELL (PHARMD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:TETT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3151 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2039
Mailing Address - Country:US
Mailing Address - Phone:619-283-7366
Mailing Address - Fax:619-283-4485
Practice Address - Street 1:3151 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-2039
Practice Address - Country:US
Practice Address - Phone:619-283-7366
Practice Address - Fax:619-283-4485
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA65348OtherPHARMACY LICENSE #