Provider Demographics
NPI:1073792099
Name:FORTIN, GLENN (RPH)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:FORTIN
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 1:12 FOSTER AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02050-3813
Mailing Address - Country:US
Mailing Address - Phone:781-499-4003
Mailing Address - Fax:781-499-4006
Practice Address - Street 1:35 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-2317
Practice Address - Country:US
Practice Address - Phone:781-499-4003
Practice Address - Fax:781-499-4006
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21965183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist