Provider Demographics
NPI:1770724965
Name:GLEN, MICHAEL ALEXANDER (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALEXANDER
Last Name:GLEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:HAGGEN FOOD AND PHARMACY
Mailing Address - Street 2:1815 MAIN STREET
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248
Mailing Address - Country:US
Mailing Address - Phone:360-380-7210
Mailing Address - Fax:360-380-7228
Practice Address - Street 1:HAGGEN FOOD AND PHARMACY
Practice Address - Street 2:1815 MAIN STREET
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248
Practice Address - Country:US
Practice Address - Phone:360-380-7210
Practice Address - Fax:360-380-7228
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-17
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51983183500000X
WAPH60216257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty