Provider Demographics
NPI:1851602528
Name:GLASS, MARY H
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:H
Last Name:GLASS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:H
Other - Last Name:PSENCIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1106 CULEBRA RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201-6005
Mailing Address - Country:US
Mailing Address - Phone:210-734-0805
Mailing Address - Fax:210-734-0630
Practice Address - Street 1:1106 CULEBRA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-6005
Practice Address - Country:US
Practice Address - Phone:210-734-0805
Practice Address - Fax:210-734-0630
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21994183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX464146Medicaid