Provider Demographics
NPI:1801142112
Name:GLENN'S CORNER PHARMACY LLC
Entity type:Organization
Organization Name:GLENN'S CORNER PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:N
Authorized Official - Last Name:PARKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:229-776-3600
Mailing Address - Street 1:631 E FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:SYLVESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31791-7231
Mailing Address - Country:US
Mailing Address - Phone:229-776-3600
Mailing Address - Fax:229-776-6464
Practice Address - Street 1:631 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SYLVESTER
Practice Address - State:GA
Practice Address - Zip Code:31791-7231
Practice Address - Country:US
Practice Address - Phone:229-776-3600
Practice Address - Fax:229-776-6464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6730230001Medicare NSC