Healthcare Provider Details

I. General information

NPI: 1891421830
Provider Name (Legal Business Name): JEFFREY L RUSSELL PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2022
Last Update Date: 07/30/2022
Certification Date: 07/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 25TH ST NW
CLEVELAND TN
37311-3830
US

IV. Provider business mailing address

135 POWHATAN DR NE
CLEVELAND TN
37323-5780
US

V. Phone/Fax

Practice location:
  • Phone: 423-614-4810
  • Fax:
Mailing address:
  • Phone: 423-584-5287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number46492
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: