Provider Demographics
NPI:1548432651
Name:MINTZ, GLENN HARVEY (RPH)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:HARVEY
Last Name:MINTZ
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 1:720 JACKIE LN
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4510
Mailing Address - Country:US
Mailing Address - Phone:516-379-9075
Mailing Address - Fax:
Practice Address - Street 1:231 W MERRICK RD
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-5514
Practice Address - Country:US
Practice Address - Phone:516-593-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY36306-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist