Provider Demographics
NPI:1417515768
Name:GLAZA, MELISSA (RPH)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GLAZA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-2326
Mailing Address - Country:US
Mailing Address - Phone:517-515-0621
Mailing Address - Fax:
Practice Address - Street 1:2540 E SAGINAW HWY
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-9719
Practice Address - Country:US
Practice Address - Phone:517-903-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-02
Last Update Date:2019-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020291591835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302029159OtherSTATE OF MICHIGAN BOARD OF PHARMACY