Provider Demographics
NPI:1801397914
Name:GLANDER INC
Entity Type:Organization
Organization Name:GLANDER INC
Other - Org Name:GLANDER PRESCRIPTIONS PLUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-459-2755
Mailing Address - Street 1:3529 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1865
Mailing Address - Country:US
Mailing Address - Phone:920-459-2755
Mailing Address - Fax:920-803-7519
Practice Address - Street 1:3529 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1865
Practice Address - Country:US
Practice Address - Phone:920-459-2755
Practice Address - Fax:920-803-7519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI8557423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33158600Medicaid
2176009OtherPK