Provider Demographics
NPI:1235668906
Name:GLORY PHARMACY, INC.
Entity Type:Organization
Organization Name:GLORY PHARMACY, INC.
Other - Org Name:THE MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:NORA
Authorized Official - Middle Name:
Authorized Official - Last Name:ISKANDAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-542-9365
Mailing Address - Street 1:9675 MONTE VISTA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9675 MONTE VISTA AVE STE A
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2213
Practice Address - Country:US
Practice Address - Phone:626-234-3186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-07
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251F00000X, 3336L0003X
CAPHY556693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No251F00000XAgenciesHome Infusion
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY55669OtherPHARMACY PERMIT
CA5663427OtherNCPDP
CA1235668906Medicaid