Healthcare Provider Details

I. General information

NPI: 1548367774
Provider Name (Legal Business Name): KENNETH SAMUEL GLOVER II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 MIDWAY PLAZA
DORA AL
35062
US

IV. Provider business mailing address

2371 HWY 78
DORA AL
35062
US

V. Phone/Fax

Practice location:
  • Phone: 205-648-9918
  • Fax: 205-648-9644
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number105923
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KENNETH SAMUEL GLOVER II
Title or Position: OWNER
Credential: RPH
Phone: 205-648-9918