Provider Demographics
NPI:1801905476
Name:RUSSELLS FISHER PHARMACY, INC.
Entity type:Organization
Organization Name:RUSSELLS FISHER PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GALLIZZI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-875-5384
Mailing Address - Street 1:3011 W GRAND BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3096
Mailing Address - Country:US
Mailing Address - Phone:313-875-5384
Mailing Address - Fax:313-875-5490
Practice Address - Street 1:3011 W GRAND BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3096
Practice Address - Country:US
Practice Address - Phone:313-875-5384
Practice Address - Fax:313-875-5490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010043743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2340292Medicaid
MI2340292OtherNABP NUMBER
MI2340292OtherNABP NUMBER