Provider Demographics
NPI:1396063772
Name:COTTRILL, GLENN
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:COTTRILL
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 1:930 MAR WALT DR STE D
Mailing Address - Street 2:
Mailing Address - City:FT. WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547
Mailing Address - Country:US
Mailing Address - Phone:850-863-5959
Mailing Address - Fax:850-863-5977
Practice Address - Street 1:930 MAR WALT DR STE D
Practice Address - Street 2:
Practice Address - City:FT. WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547
Practice Address - Country:US
Practice Address - Phone:850-863-5959
Practice Address - Fax:850-863-5977
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-11
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR31332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies