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 1:2150 E DUBLIN GRANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-3513
Mailing Address - Country:US
Mailing Address - Phone:614-523-1165
Mailing Address - Fax:614-523-1386
Practice Address - Street 1:2150 E DUBLIN GRANVILLE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-4110
Practice Address - Country:US
Practice Address - Phone:614-523-1165
Practice Address - Fax:614-523-1386
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH033241751835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist