Provider Demographics
NPI:1205405248
Name:GLENDALE PHARMACY LLC
Entity Type:Organization
Organization Name:GLENDALE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GITAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-981-6163
Mailing Address - Street 1:4203 GARDENDALE ST STE 223C
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3177
Mailing Address - Country:US
Mailing Address - Phone:210-617-5507
Mailing Address - Fax:
Practice Address - Street 1:4203 GARDENDALE ST STE 223C
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3177
Practice Address - Country:US
Practice Address - Phone:210-617-5507
Practice Address - Fax:210-617-4575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-23
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy