Provider Demographics
NPI:1639353113
Name:DAVIS, GLENN RICHARD
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:RICHARD
Last Name:DAVIS
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 1:985 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-2905
Mailing Address - Country:US
Mailing Address - Phone:585-872-1380
Mailing Address - Fax:585-872-1398
Practice Address - Street 1:985 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-2905
Practice Address - Country:US
Practice Address - Phone:585-872-1380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33747183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02519359Medicaid