MEDICARE: MR. GLENN R MILAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	0202204690	VA

General Provider Information

NPI Number	:	1750349833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GLENN R MILAM

Provider Business Mailing Address
First Line	:	1712 LAUREL GROVE RD
Second Line	:
City	:	SUTHERLIN
State	:	VA
Zip	:	24594-3540
Country	:	US
Telephone Number	:	434-793-5711
Fax Number	:

Provider Business Practice Location Address
First Line	:	155 S MAIN ST
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24541-2921
Country	:	US
Telephone Number	:	434-793-5711
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	07/08/2007

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