=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871269589
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANIEL DONALD RUSSO PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2021
-----------------------------------------------------
Last Update Date | 08/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 461 COOKE ST
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06032-3012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-955-0255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 461 COOKE ST
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06032-3012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-955-0255
-----------------------------------------------------
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 | PCT.0015255
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------