Provider Demographics
NPI:1235966193
Name:RUSSELL, JESSICA (PHARMACIST)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 HERITAGE ESTATES LN
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-7525
Mailing Address - Country:US
Mailing Address - Phone:256-975-7225
Mailing Address - Fax:
Practice Address - Street 1:2630 LPGA BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32124-1008
Practice Address - Country:US
Practice Address - Phone:386-281-6780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS67629183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist