Provider Demographics
NPI:1962472472
Name:LAIRD, GLENN L (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:L
Last Name:LAIRD
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:733 DENISE DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-5423
Mailing Address - Country:US
Mailing Address - Phone:850-883-8445
Mailing Address - Fax:850-883-8429
Practice Address - Street 1:307 BOATNER RD
Practice Address - Street 2:SUITE NUMBER 114
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1391
Practice Address - Country:US
Practice Address - Phone:850-883-8445
Practice Address - Fax:850-883-8429
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-09281183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist