MEDICARE: MISS JEANNE MARIA RUSSOW RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	P4821	ID

General Provider Information

NPI Number	:	1255603999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JEANNE MARIA RUSSOW RPH

Provider Business Mailing Address
First Line	:	731 POLE LINE RD
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-3036
Country	:	US
Telephone Number	:	208-736-1725
Fax Number	:	208-736-7318

Provider Business Practice Location Address
First Line	:	731 POLE LINE RD
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-3036
Country	:	US
Telephone Number	:	208-736-1725
Fax Number	:	208-736-7318

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2012
Last Update Date	:	01/26/2012

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