Provider Demographics
NPI:1003827502
Name:GLENWOOD PHARMACY INC
Entity Type:Organization
Organization Name:GLENWOOD PHARMACY INC
Other - Org Name:RIVERSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-476-5727
Mailing Address - Street 1:1105 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:OROFINO
Mailing Address - State:ID
Mailing Address - Zip Code:83544-9005
Mailing Address - Country:US
Mailing Address - Phone:208-476-0329
Mailing Address - Fax:208-476-0349
Practice Address - Street 1:13040 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-9330
Practice Address - Country:US
Practice Address - Phone:208-476-0329
Practice Address - Fax:208-476-0349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID19201RP333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135971OtherPK