1245465467 NPI number — DR. RYAN MICHAEL RUSSELL PHARMD.

Table of content: DR. RYAN MICHAEL RUSSELL PHARMD. (NPI 1245465467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245465467 NPI number — DR. RYAN MICHAEL RUSSELL PHARMD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
RYAN
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245465467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2911 RUSSELL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63104-1536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-771-3269
Provider Business Mailing Address Fax Number:
314-344-6179

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12266 DE PAUL DR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
BRIDGETON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63044-2514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-344-7300
Provider Business Practice Location Address Fax Number:
314-344-7179
Provider Enumeration Date:
05/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  2006024046 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 183500000X , with the licence number: 051287298 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 606172302 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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