MEDICARE: RUSSELL'S PHARMACY, INC

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	840	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	840	OTHER	TN	STATE PHARMACY NUMBER

General Provider Information

NPI Number	:	1669470084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSELL'S PHARMACY, INC

Provider Business Mailing Address
First Line	:	2455 CHELSEA AVE
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38108-2404
Country	:	US
Telephone Number	:	901-327-7323
Fax Number	:	901-323-0228

Provider Business Practice Location Address
First Line	:	2455 CHELSEA AVE
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38108-2404
Country	:	US
Telephone Number	:	901-327-7323
Fax Number	:	901-323-0228

Authorized Official
Title or Position	:	PRESIDENT/PHARMACIST
Name	:	DR. KENNETH THOMAS STEWART
Credential	:	DPH
Telephone Number	:	901-327-7323

Provider Enumeration Date	:	07/09/2005
Last Update Date	:	03/07/2023

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