Healthcare Provider Details

I. General information

NPI: 1295324572
Provider Name (Legal Business Name): MR. MICHAEL C RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 US 41 W
ISHPEMING MI
49849-3152
US

IV. Provider business mailing address

1330 US 41 W
ISHPEMING MI
49849-3152
US

V. Phone/Fax

Practice location:
  • Phone: 906-250-7034
  • Fax: 906-485-4482
Mailing address:
  • Phone: 906-250-7034
  • Fax: 906-485-4482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302027203
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: