Healthcare Provider Details

I. General information

NPI: 1700849718
Provider Name (Legal Business Name): GIRIACO RUSSO RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 MAPLE ST
NAUGATUCK CT
06770-4256
US

IV. Provider business mailing address

1 RANAUDO ST
WATERBURY CT
06708-4704
US

V. Phone/Fax

Practice location:
  • Phone: 203-729-2297
  • Fax: 203-729-1134
Mailing address:
  • Phone: 203-768-7355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4813
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: