Provider Demographics
NPI:1144505132
Name:RUSSELL, DINA (RPH)
Entity type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 WESTVIEW ROAD
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052
Mailing Address - Country:US
Mailing Address - Phone:508-359-1053
Mailing Address - Fax:
Practice Address - Street 1:1 WRENTHAM STREET
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02019
Practice Address - Country:US
Practice Address - Phone:508-883-1907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20269183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist