Provider Demographics
NPI:1306138813
Name:ABERNATHY, RUSSELL GLENN (RPH)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:GLENN
Last Name:ABERNATHY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 US 70
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD COLLEGE
Mailing Address - State:NC
Mailing Address - Zip Code:28671
Mailing Address - Country:US
Mailing Address - Phone:828-874-2119
Mailing Address - Fax:828-874-0161
Practice Address - Street 1:300 MAIN AVE W
Practice Address - Street 2:
Practice Address - City:HILDEBRAN
Practice Address - State:NC
Practice Address - Zip Code:28637-8315
Practice Address - Country:US
Practice Address - Phone:828-397-3420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10857183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0125435Medicaid