Provider Demographics
NPI:1235301383
Name:PIERSON, GLEN COREY (RPH)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:COREY
Last Name:PIERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13603 BANDIX RD SE
Mailing Address - Street 2:
Mailing Address - City:OLALLA
Mailing Address - State:WA
Mailing Address - Zip Code:98359-9469
Mailing Address - Country:US
Mailing Address - Phone:253-302-9024
Mailing Address - Fax:
Practice Address - Street 1:13603 BANDIX RD SE
Practice Address - Street 2:
Practice Address - City:OLALLA
Practice Address - State:WA
Practice Address - Zip Code:98359-9469
Practice Address - Country:US
Practice Address - Phone:253-302-9024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00015079183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy