Provider Demographics
NPI:1790255768
Name:BURNETT, GLEN (RPH)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:BURNETT
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 1:1624 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:OK
Mailing Address - Zip Code:74350
Mailing Address - Country:US
Mailing Address - Phone:918-782-9619
Mailing Address - Fax:
Practice Address - Street 1:1624 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LANGLEY
Practice Address - State:OK
Practice Address - Zip Code:74350
Practice Address - Country:US
Practice Address - Phone:918-782-9619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK113721835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist