Provider Demographics
NPI:1053584045
Name:LEDERHOUSE, RUSSELL T (PHARMD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:T
Last Name:LEDERHOUSE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 FAWN HAVEN CT
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405-5858
Mailing Address - Country:US
Mailing Address - Phone:304-262-0104
Mailing Address - Fax:
Practice Address - Street 1:2207 VALLEY AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2755
Practice Address - Country:US
Practice Address - Phone:540-667-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202207604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist