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General NPI Number Information
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NPI Number | 1376897660
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Entity Type | Individual
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Provider Name | GREGORY S RUSSELL PHARM.D
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Gender | Male
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Dates
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Enumeration Date | 11/08/2012
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Last Update Date | 11/08/2012
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Provider Practice Location Address
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Address Line | 414 E DUPONT RD
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City | FORT WAYNE
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State | IN
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Zip | 46825-2050
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Country | US
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Telephone | 260-490-3447
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Fax | 260-490-3457
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Provider Business Mailing Address
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Address Line | 414 E DUPONT RD
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City | FORT WAYNE
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State | IN
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Zip | 46825-2050
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Country | US
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Telephone | 260-490-3447
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Fax | 260-490-3457
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 26015397A
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License Number State | IN
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