Provider Demographics
NPI:1457631178
Name:GLAZE, PHILLIP C (DPH)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:C
Last Name:GLAZE
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 US HIGHWAY 31 N
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35611-2142
Mailing Address - Country:US
Mailing Address - Phone:256-230-2799
Mailing Address - Fax:256-230-2839
Practice Address - Street 1:101 US HIGHWAY 31 N
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-2142
Practice Address - Country:US
Practice Address - Phone:256-230-2799
Practice Address - Fax:256-230-2839
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10271183500000X
TN8719183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL10271OtherPHARMACIST LICENSE
TN8719OtherPHARMACIST LICENSE