Healthcare Provider Details

I. General information

NPI: 1205104692
Provider Name (Legal Business Name): DEVIN JORDAN RUSSELL PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 MARKET ST
RED BOILING SPRINGS TN
37150-2271
US

IV. Provider business mailing address

PO BOX 59
RED BOILING SPRINGS TN
37150-0059
US

V. Phone/Fax

Practice location:
  • Phone: 615-699-2509
  • Fax: 615-699-4139
Mailing address:
  • Phone: 615-699-2509
  • Fax: 615-699-4139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0000028852
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: