Provider Demographics
NPI:1154003929
Name:RUSS, KENNETH LAWRENCE
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LAWRENCE
Last Name:RUSS
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 1:101 ALLEN TOUSSAINT BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70124-2560
Mailing Address - Country:US
Mailing Address - Phone:504-282-2203
Mailing Address - Fax:504-282-2209
Practice Address - Street 1:101 ALLEN TOUSSAINT BLVD
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70124-2560
Practice Address - Country:US
Practice Address - Phone:504-282-2203
Practice Address - Fax:504-282-2209
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAQ9N2E4L2183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty