Provider Demographics
NPI:1013290378
Name:GLENN, KELLY ELAINE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELAINE
Last Name:GLENN
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 1:10107 LIZETTE CT.
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77075
Mailing Address - Country:US
Mailing Address - Phone:713-291-5838
Mailing Address - Fax:
Practice Address - Street 1:10107 LIZETTE CT
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77075-4807
Practice Address - Country:US
Practice Address - Phone:713-291-5838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41118183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1306851381OtherWALGREENS