Provider Demographics
NPI:1457348047
Name:GLENN, JOHN D (RPH,CDE)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:GLENN
Suffix:
Gender:M
Credentials:RPH,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 NW PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-0049
Mailing Address - Country:US
Mailing Address - Phone:912-367-2488
Mailing Address - Fax:912-367-7235
Practice Address - Street 1:34 NW PARK AVE
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0049
Practice Address - Country:US
Practice Address - Phone:912-367-2488
Practice Address - Fax:912-367-7235
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12138183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist