Healthcare Provider Details

I. General information

NPI: 1356385322
Provider Name (Legal Business Name): DENNIS L. RUSSELL R.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 H ST
FAIRBURY NE
68352-1119
US

IV. Provider business mailing address

20725 S 5TH DR
BEATRICE NE
68310-6889
US

V. Phone/Fax

Practice location:
  • Phone: 402-729-3351
  • Fax: 402-729-2102
Mailing address:
  • Phone: 402-228-4123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8583
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: