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General NPI Number Information
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NPI Number | 1932700424
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Entity Type | Individual
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Provider Name | CHANDRA NICHOLE RUSSELL
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Gender | Female
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Dates
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Enumeration Date | 11/03/2020
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Last Update Date | 11/03/2020
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Provider Practice Location Address
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Address Line | 3116 S GARNETT RD
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City | TULSA
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State | OK
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Zip | 74146-1933
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Country | US
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Telephone | 918-622-7923
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Fax |
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Provider Business Mailing Address
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Address Line | 2750 N 7TH ST APT 4121
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City | BROKEN ARROW
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State | OK
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Zip | 74012-2874
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Country | US
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Telephone | 918-606-8286
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Fax |
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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 | 18136
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License Number State | PW
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