Provider Demographics
NPI:1942889654
Name:BORDEN, GLENN
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:BORDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21321 ROCK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-4876
Mailing Address - Country:US
Mailing Address - Phone:561-706-7803
Mailing Address - Fax:561-241-7711
Practice Address - Street 1:4802 NW 2ND AVE
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-4173
Practice Address - Country:US
Practice Address - Phone:561-241-7711
Practice Address - Fax:561-241-7717
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS27542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL84-2217583Medicaid