Healthcare Provider Details

I. General information

NPI: 1528118932
Provider Name (Legal Business Name): GLENDON EARL GRAVLEE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6456 AL HWY 269
PARRISH AL
35580
US

IV. Provider business mailing address

2408 WOODLEY DR
JASPER AL
35504-9456
US

V. Phone/Fax

Practice location:
  • Phone: 205-648-9945
  • Fax: 205-648-9993
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9125
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: