Provider Demographics
NPI:1972670362
Name:STOKEM, GLENN (RPH)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:STOKEM
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 624
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NY
Mailing Address - Zip Code:12865-0624
Mailing Address - Country:US
Mailing Address - Phone:518-854-3781
Mailing Address - Fax:518-854-3827
Practice Address - Street 1:205 MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NY
Practice Address - Zip Code:12865-0624
Practice Address - Country:US
Practice Address - Phone:518-854-3781
Practice Address - Fax:518-854-3827
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31070183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02510612Medicaid