Provider Demographics
NPI:1871874255
Name:RUSSELL, TRAE A (RPH)
Entity type:Individual
Prefix:MR
First Name:TRAE
Middle Name:A
Last Name:RUSSELL
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 1:5440 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1210
Mailing Address - Country:US
Mailing Address - Phone:773-596-5022
Mailing Address - Fax:773-506-3837
Practice Address - Street 1:5440 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1210
Practice Address - Country:US
Practice Address - Phone:773-596-5022
Practice Address - Fax:773-506-3837
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2025-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0513062171835P0018X
OH03324175183500000X, 1835P0018X
IL051.306217183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist