Provider Demographics
NPI:1891829677
Name:ROBERTS, GLENN DANIEL (RPH)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:DANIEL
Last Name:ROBERTS
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:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:TCHULA
Mailing Address - State:MS
Mailing Address - Zip Code:39169-0217
Mailing Address - Country:US
Mailing Address - Phone:662-235-4422
Mailing Address - Fax:
Practice Address - Street 1:112 MERCER ST
Practice Address - Street 2:
Practice Address - City:TCHULA
Practice Address - State:MS
Practice Address - Zip Code:39169
Practice Address - Country:US
Practice Address - Phone:662-235-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-07015183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist