Provider Demographics
NPI:1568079960
Name:WINEGEART, GLEN AVERY
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:AVERY
Last Name:WINEGEART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 HWY 69 NORTH
Mailing Address - Street 2:
Mailing Address - City:BULLARD
Mailing Address - State:TX
Mailing Address - Zip Code:75757
Mailing Address - Country:US
Mailing Address - Phone:903-894-9648
Mailing Address - Fax:
Practice Address - Street 1:213 US HIGHWAY 69 N
Practice Address - Street 2:
Practice Address - City:BULLARD
Practice Address - State:TX
Practice Address - Zip Code:75757-5135
Practice Address - Country:US
Practice Address - Phone:903-894-9648
Practice Address - Fax:866-569-0759
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24094183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist