Provider Demographics
NPI:1326165150
Name:STARK, GLENN WILLIAM (RPH)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:WILLIAM
Last Name:STARK
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 1:1021 WESBEND DR
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-9782
Mailing Address - Country:US
Mailing Address - Phone:502-875-3865
Mailing Address - Fax:
Practice Address - Street 1:1230 US HIGHWAY 127 S
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-4319
Practice Address - Country:US
Practice Address - Phone:502-875-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist