Healthcare Provider Details

I. General information

NPI: 1417009788
Provider Name (Legal Business Name): MARTIN ANTHONY RUSSELL PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WRAMC BLDG DEPT OF PHARMACY 6900 GEORGIA AVE NW
WASHINGTON DC
20307-0001
US

IV. Provider business mailing address

4808 DERUSSEY PKWY
CHEVY CHASE MD
20815-5328
US

V. Phone/Fax

Practice location:
  • Phone: 202-782-6224
  • Fax:
Mailing address:
  • Phone: 202-256-5952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17407
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: