Provider Demographics
NPI:1578272845
Name:MATHIA, GLEN DALE
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:DALE
Last Name:MATHIA
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 1:5900 W PLEASANT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-4427
Mailing Address - Country:US
Mailing Address - Phone:817-468-6041
Mailing Address - Fax:817-478-6069
Practice Address - Street 1:5900 W PLEASANT RIDGE RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76016-4427
Practice Address - Country:US
Practice Address - Phone:817-468-6041
Practice Address - Fax:817-478-6069
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29993183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist