MEDICARE: DR. MICHAEL RUSSELL PHARMD

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	051.292600	IL

General Provider Information

NPI Number	:	1780289504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL RUSSELL PHARMD

Provider Business Mailing Address
First Line	:	208 W JACKSON ST
Second Line	:
City	:	SULLIVAN
State	:	IL
Zip	:	61951-1454
Country	:	US
Telephone Number	:	217-728-7216
Fax Number	:	217-728-2816

Provider Business Practice Location Address
First Line	:	208 W JACKSON ST
Second Line	:
City	:	SULLIVAN
State	:	IL
Zip	:	61951-1454
Country	:	US
Telephone Number	:	217-728-7216
Fax Number	:	217-728-2816

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

Provider Enumeration Date	:	12/01/2020
Last Update Date	:	12/01/2020

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