Provider Demographics
NPI:1881036507
Name:SHIELDS, GLENN PAUL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:PAUL
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 KINGS BOTTOM DR
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-7601
Mailing Address - Country:US
Mailing Address - Phone:704-301-4651
Mailing Address - Fax:
Practice Address - Street 1:4514 OLD MONROE RD STE A
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-5308
Practice Address - Country:US
Practice Address - Phone:704-301-4651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist