Provider Demographics
NPI:1265026728
Name:CHANITTHIKUL, GLENN (PHARMD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:CHANITTHIKUL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-1948
Mailing Address - Country:US
Mailing Address - Phone:574-307-7685
Mailing Address - Fax:574-307-7683
Practice Address - Street 1:420 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1948
Practice Address - Country:US
Practice Address - Phone:574-307-7685
Practice Address - Fax:574-307-7683
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051302873183500000X
OH03440404183500000X
MO2020033888183500000X
IN26029067A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist