Provider Demographics
NPI:1881151942
Name:RUSSO, CANDACE RAE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:CANDACE
Middle Name:RAE
Last Name:RUSSO
Suffix:
Gender:
Credentials:PHARMD
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:RAE
Other - Last Name:STIFFLEMIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 W BEECH ST STE 503
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2669
Mailing Address - Country:US
Mailing Address - Phone:979-567-1177
Mailing Address - Fax:
Practice Address - Street 1:8915 TOWNE CENTRE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5650
Practice Address - Country:US
Practice Address - Phone:858-550-9066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79660183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist