Provider Demographics
NPI:1992082374
Name:STEVENSON, RUSSELL G JR (BS, MA, RPH)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:G
Last Name:STEVENSON
Suffix:JR
Gender:M
Credentials:BS, MA, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6942 W OLIVE AVE LOT 67
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-7266
Mailing Address - Country:US
Mailing Address - Phone:602-832-4269
Mailing Address - Fax:
Practice Address - Street 1:6942 W OLIVE AVE LOT 67
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-7266
Practice Address - Country:US
Practice Address - Phone:602-832-4269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-13
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS12743183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist