Provider Demographics
NPI:1114960994
Name:GLENDALE PRESCRIPTION CENTER INC
Entity Type:Organization
Organization Name:GLENDALE PRESCRIPTION CENTER INC
Other - Org Name:MD CUSTOM RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONICA MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZATARSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-967-9248
Mailing Address - Street 1:5322 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5322 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4913
Practice Address - Country:US
Practice Address - Phone:414-967-9248
Practice Address - Fax:414-967-9548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI85060423336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5128738OtherOTHER ID NUMBER-COMMERCIAL NUMBER