=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306147749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSSO'S PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2010
-----------------------------------------------------
Last Update Date | 11/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1909 CORNAGA AVE
-----------------------------------------------------
City | FAR ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691-4303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-568-7338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1909 CORNAGA AVE
-----------------------------------------------------
City | FAR ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691-4303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DANIEL RUSSO
-----------------------------------------------------
Credential | PHARMD, RPH.I
-----------------------------------------------------
Telephone | 516-568-7338
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------