Provider Demographics
NPI:1861494312
Name:ROBERTS, RUSSEL JOSEPH (PHARMD, FCCM, BCCC)
Entity type:Individual
Prefix:DR
First Name:RUSSEL
Middle Name:JOSEPH
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PHARMD, FCCM, BCCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 DURHAM RD
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-5328
Mailing Address - Country:US
Mailing Address - Phone:314-346-7877
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:GRB-005
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:314-346-7877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030002941835P1200X, 1835C0205X, 1835P0018X
MAPH272021835C0205X, 1835P0018X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835C0205XPharmacy Service ProvidersPharmacistCritical Care
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist