Provider Demographics
NPI:1508460817
Name:GLENN, PATRICIA LOUISE
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LOUISE
Last Name:GLENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:LOUISE
Other - Last Name:TENNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2123 BAYOU DR
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34691-9717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11500 RIDGE RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34654-6400
Practice Address - Country:US
Practice Address - Phone:727-856-1334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS23334183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist