Provider Demographics
NPI:1760855704
Name:ANDERSON, GLEN
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:ANDERSON
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 1:31 TENNIS VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:HEATH
Mailing Address - State:TX
Mailing Address - Zip Code:75032-5995
Mailing Address - Country:US
Mailing Address - Phone:972-679-9003
Mailing Address - Fax:
Practice Address - Street 1:31 TENNIS VILLAGE DR
Practice Address - Street 2:
Practice Address - City:HEATH
Practice Address - State:TX
Practice Address - Zip Code:75032-5995
Practice Address - Country:US
Practice Address - Phone:972-679-9003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX284581835G0303X
AL104031835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric