Healthcare Provider Details

I. General information

NPI: 1699816785
Provider Name (Legal Business Name): GLENN E LESLIE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 RAINBOW DR
GADSDEN AL
35901-5309
US

IV. Provider business mailing address

911 RAINBOW DR
GADSDEN AL
35901-5309
US

V. Phone/Fax

Practice location:
  • Phone: 256-547-4479
  • Fax: 256-549-0577
Mailing address:
  • Phone: 256-547-4479
  • Fax: 256-549-0577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11682
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: