Provider Demographics
NPI:1912334152
Name:THOM, RUSSELL ALAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:ALAN
Last Name:THOM
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 1:15728 S AVENUE 5 E
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-8012
Mailing Address - Country:US
Mailing Address - Phone:520-664-5499
Mailing Address - Fax:
Practice Address - Street 1:2491 W 24TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6153
Practice Address - Country:US
Practice Address - Phone:928-341-0589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ020184183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist