Provider Demographics
NPI:1396946117
Name:GILBREATH, GLENN H JR (DPH)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:H
Last Name:GILBREATH
Suffix:JR
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-5409
Mailing Address - Country:US
Mailing Address - Phone:405-224-2858
Mailing Address - Fax:
Practice Address - Street 1:2120 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-6810
Practice Address - Country:US
Practice Address - Phone:405-222-0278
Practice Address - Fax:405-222-0693
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2009-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10220183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist