Provider Demographics
NPI:1205449154
Name:HALL, GLENN WALLACE (RPH)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:WALLACE
Last Name:HALL
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 1:915 VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-6759
Mailing Address - Country:US
Mailing Address - Phone:707-542-1879
Mailing Address - Fax:707-542-4615
Practice Address - Street 1:915 VILLAGE CT
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6759
Practice Address - Country:US
Practice Address - Phone:707-542-1879
Practice Address - Fax:707-542-4615
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH60664183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist