Provider Demographics
NPI:1396022992
Name:GLENNON, BEN A (RPH)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:A
Last Name:GLENNON
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 1:2870 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1224
Mailing Address - Country:US
Mailing Address - Phone:720-214-3853
Mailing Address - Fax:720-214-3859
Practice Address - Street 1:2870 28TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1224
Practice Address - Country:US
Practice Address - Phone:720-214-3853
Practice Address - Fax:720-214-3859
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17237183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist