Provider Demographics
NPI:1649585647
Name:GIAMBRONE, GLEN (RPH)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:
Last Name:GIAMBRONE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 N CANAL BLVD
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-2995
Mailing Address - Country:US
Mailing Address - Phone:985-447-2456
Mailing Address - Fax:985-447-6572
Practice Address - Street 1:195 N CANAL BLVD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-2995
Practice Address - Country:US
Practice Address - Phone:985-447-2456
Practice Address - Fax:985-447-6572
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15877183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist