Provider Demographics
NPI:1245836279
Name:ROYALL, GLEN
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:
Last Name:ROYALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8130 LEVY COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4120
Mailing Address - Country:US
Mailing Address - Phone:817-991-9517
Mailing Address - Fax:
Practice Address - Street 1:2440 GILMER RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-2134
Practice Address - Country:US
Practice Address - Phone:903-241-2971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-06
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX53762183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist