Provider Demographics
NPI:1598922288
Name:GLISSON, MICHELLE LEDESMA
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEDESMA
Last Name:GLISSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 104
Mailing Address - Street 2:377 TUCKER RD
Mailing Address - City:CLAXTON
Mailing Address - State:GA
Mailing Address - Zip Code:30417-0104
Mailing Address - Country:US
Mailing Address - Phone:912-739-3822
Mailing Address - Fax:
Practice Address - Street 1:114 W BARNARD ST
Practice Address - Street 2:
Practice Address - City:GLENNVILLE
Practice Address - State:GA
Practice Address - Zip Code:30427-2000
Practice Address - Country:US
Practice Address - Phone:912-654-3031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA18775183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist