=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356385322
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENNIS L. RUSSELL R.P.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2006
-----------------------------------------------------
Last Update Date | 07/10/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 H ST
-----------------------------------------------------
City | FAIRBURY
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68352-1119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-729-3351
-----------------------------------------------------
Fax | 402-729-2102
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20725 S 5TH DR
-----------------------------------------------------
City | BEATRICE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68310-6889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-228-4123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 8583
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------