Healthcare Provider Details

I. General information

NPI: 1255463568
Provider Name (Legal Business Name): JON RUSSELL R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E BROAD ST
HAZLETON PA
18201-6520
US

IV. Provider business mailing address

477 STRAWBERRY LN
MOUNTAIN TOP PA
18707-1559
US

V. Phone/Fax

Practice location:
  • Phone: 570-454-2476
  • Fax:
Mailing address:
  • Phone: 570-403-7785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP039898L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: