Provider Demographics
NPI:1629345244
Name:GLENN, TERRALEE
Entity Type:Individual
Prefix:
First Name:TERRALEE
Middle Name:
Last Name:GLENN
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 1:6359 MARVIN RD
Mailing Address - Street 2:
Mailing Address - City:HOLTON
Mailing Address - State:MI
Mailing Address - Zip Code:49425-9535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1771 HOLTON RD
Practice Address - Street 2:
Practice Address - City:NORTH MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1452
Practice Address - Country:US
Practice Address - Phone:231-744-1391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021198183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist