Provider Demographics
NPI:1093818429
Name:GLENDALE CLINIC PHARMACY INC
Entity Type:Organization
Organization Name:GLENDALE CLINIC PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILE
Authorized Official - Middle Name:
Authorized Official - Last Name:DALAL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:414-362-9560
Mailing Address - Street 1:9233 N GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209
Mailing Address - Country:US
Mailing Address - Phone:414-362-9560
Mailing Address - Fax:414-270-8140
Practice Address - Street 1:9233 N GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53209
Practice Address - Country:US
Practice Address - Phone:414-362-9560
Practice Address - Fax:414-270-8140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33143100Medicaid
WI33143100Medicaid
5107621Medicare UPIN