Provider Demographics
NPI:1962810317
Name:RUSSO, NICOLE BROOKE (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:BROOKE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 SHELDON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-2115
Mailing Address - Country:US
Mailing Address - Phone:718-825-4645
Mailing Address - Fax:
Practice Address - Street 1:2754 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-4658
Practice Address - Country:US
Practice Address - Phone:718-980-2059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059546183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist