Provider Demographics
NPI:1376958884
Name:GLAZE, BOBBY (PHARMD)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:GLAZE
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 1:4018 BROOKFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2004
Mailing Address - Country:US
Mailing Address - Phone:870-833-1194
Mailing Address - Fax:
Practice Address - Street 1:2360 STONY BROOK DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-4018
Practice Address - Country:US
Practice Address - Phone:502-493-8719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY017116183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist