Provider Demographics
NPI:1134114903
Name:REX, GLENN RUSTY (DPH)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:RUSTY
Last Name:REX
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 W 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-1603
Mailing Address - Country:US
Mailing Address - Phone:405-747-8999
Mailing Address - Fax:
Practice Address - Street 1:RR 2 BOX 247
Practice Address - Street 2:
Practice Address - City:STROUD
Practice Address - State:OK
Practice Address - Zip Code:74079-9652
Practice Address - Country:US
Practice Address - Phone:918-968-9531
Practice Address - Fax:918-968-0113
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8894183500000X
TX20503183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist