Provider Demographics
NPI:1124328794
Name:ANDERSON, RUSSELL E
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:E
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 S ROUTE 12
Mailing Address - Street 2:
Mailing Address - City:FOX LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60020-1930
Mailing Address - Country:US
Mailing Address - Phone:847-587-4206
Mailing Address - Fax:847-587-4731
Practice Address - Street 1:1258 S ROUTE 12
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1950
Practice Address - Country:US
Practice Address - Phone:847-587-4966
Practice Address - Fax:847-587-4731
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2016-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051037672183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist