Provider Demographics
NPI:1902361389
Name:CONLEY, GLENDA LEE
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:LEE
Last Name:CONLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 PIKES CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-5417
Mailing Address - Country:US
Mailing Address - Phone:951-202-5024
Mailing Address - Fax:
Practice Address - Street 1:4646 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-0102
Practice Address - Country:US
Practice Address - Phone:951-788-4646
Practice Address - Fax:951-774-2836
Is Sole Proprietor?:No
Enumeration Date:2019-02-09
Last Update Date:2019-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40248183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist