Provider Demographics
NPI:1326050782
Name:GLENN LAKES PHARMACY, INC.
Entity Type:Organization
Organization Name:GLENN LAKES PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PHARMACY MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONA
Authorized Official - Middle Name:RACHEL
Authorized Official - Last Name:FINLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:281-261-8278
Mailing Address - Street 1:3640 GLENN LAKES LN
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-4064
Mailing Address - Country:US
Mailing Address - Phone:281-261-8278
Mailing Address - Fax:281-499-5198
Practice Address - Street 1:3640 GLENN LAKES LN
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-4064
Practice Address - Country:US
Practice Address - Phone:281-261-8278
Practice Address - Fax:281-499-5198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20540183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144978Medicaid
0883130001Medicare ID - Type Unspecified