Healthcare Provider Details

I. General information

NPI: 1811000441
Provider Name (Legal Business Name): SUSAN ANN RUSSELL RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

I-40, EXIT 102
SAN FIDEL NM
87049
US

IV. Provider business mailing address

804 WASHINGTON AVE
GRANTS NM
87020-3025
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5394
  • Fax: 505-552-5464
Mailing address:
  • Phone: 505-552-5394
  • Fax: 505-552-5464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number00005516
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: