Provider Demographics
NPI:1114209871
Name:ADAMS, GLENN
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:ADAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 HOMER RD
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-2910
Mailing Address - Country:US
Mailing Address - Phone:318-377-0131
Mailing Address - Fax:318-377-5681
Practice Address - Street 1:606 HOMER RD
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-2910
Practice Address - Country:US
Practice Address - Phone:318-377-0131
Practice Address - Fax:318-377-5681
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist