Provider Demographics
NPI:1386976827
Name:RUSSO, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RUSSO
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 1:8254 DAMPIER CIR
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-4105
Mailing Address - Country:US
Mailing Address - Phone:315-622-3062
Mailing Address - Fax:
Practice Address - Street 1:437 ELECTRONICS PKWY
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6001
Practice Address - Country:US
Practice Address - Phone:315-453-1750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044843183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist