Provider Demographics
NPI:1790856110
Name:GLENN, SAMUEL STEPHEN SR (RPH)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:STEPHEN
Last Name:GLENN
Suffix:SR
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 1:16 SECRETARIAT WAY
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-6020
Mailing Address - Country:US
Mailing Address - Phone:864-675-9256
Mailing Address - Fax:
Practice Address - Street 1:2627 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29624-3241
Practice Address - Country:US
Practice Address - Phone:864-225-3119
Practice Address - Fax:864-225-0411
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3964183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist