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General NPI Number Information
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NPI Number | 1710977442
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Entity Type | Organization
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Legal Business Name | LARRY J & BONNIE P RUSSELL
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Dates
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Enumeration Date | 10/25/2005
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 910 N DIXIE AVE STE 105
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-2519
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Country | US
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Telephone | 270-769-3717
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Fax | 270-769-2887
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Provider Business Mailing Address
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Address Line | 910 N DIXIE AVE STE 105
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-2519
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Country | US
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Telephone | 270-769-3717
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Fax | 270-769-2887
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Authorized Official
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Title or Position | OWNER
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Name | MR. LARRY RUSSELL
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Credential | R.PH.
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Telephone | 270-769-3717
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | P01397
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State | KY
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