Provider Demographics
NPI:1962462960
Name:GLSJO LLC
Entity Type:Organization
Organization Name:GLSJO LLC
Other - Org Name:HI-SCHOOL PHARMACY #1165
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKESLEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-213-2236
Mailing Address - Street 1:916 W EVERGREEN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3035
Mailing Address - Country:US
Mailing Address - Phone:360-213-2236
Mailing Address - Fax:360-213-2238
Practice Address - Street 1:33454 SW CHINOOK PLZ
Practice Address - Street 2:
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-3731
Practice Address - Country:US
Practice Address - Phone:503-543-6316
Practice Address - Fax:360-213-2238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP0000553CS333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR175026Medicaid
3804780OtherNCPDP
R144775Medicare PIN