Provider Demographics
NPI:1376893875
Name:GLENN, MARY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1071 S. LAKE DR.
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29073
Mailing Address - Country:US
Mailing Address - Phone:803-957-0605
Mailing Address - Fax:803-957-3579
Practice Address - Street 1:1071 S. LAKE DR.
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29073
Practice Address - Country:US
Practice Address - Phone:803-957-0605
Practice Address - Fax:803-957-3579
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12175183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist