Provider Demographics
NPI:1760974547
Name:GLADE LTC, LLC
Entity Type:Organization
Organization Name:GLADE LTC, LLC
Other - Org Name:GLADE LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SETH
Authorized Official - Middle Name:
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:276-776-1920
Mailing Address - Street 1:305 FALLS DR NW
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-8093
Mailing Address - Country:US
Mailing Address - Phone:276-776-1920
Mailing Address - Fax:276-776-1930
Practice Address - Street 1:305 FALLS DR NW
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-8093
Practice Address - Country:US
Practice Address - Phone:276-776-1920
Practice Address - Fax:276-776-1930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-06
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010042053336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1760974547Medicaid
VA1669656179Medicaid