Provider Demographics
NPI:1669656179
Name:GLADE PHARMACY LLC
Entity Type:Organization
Organization Name:GLADE PHARMACY LLC
Other - Org Name:GLADE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:276-429-2004
Mailing Address - Street 1:33472 LEE HWY
Mailing Address - Street 2:
Mailing Address - City:GLADE SPRING
Mailing Address - State:VA
Mailing Address - Zip Code:24340-5100
Mailing Address - Country:US
Mailing Address - Phone:276-429-2004
Mailing Address - Fax:276-429-2009
Practice Address - Street 1:33472 LEE HWY
Practice Address - Street 2:
Practice Address - City:GLADE SPRING
Practice Address - State:VA
Practice Address - Zip Code:24340-5100
Practice Address - Country:US
Practice Address - Phone:276-429-2004
Practice Address - Fax:276-429-2009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201004205333600000X
TN44893336C0003X
3336L0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA166965617AMedicaid
2106327OtherPK