Healthcare Provider Details

I. General information

NPI: 1396659199
Provider Name (Legal Business Name): KAELEN GLAZE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7827 LAKE UNDERHILL RD
ORLANDO FL
32822
US

IV. Provider business mailing address

421 WILLOW LAKE DR
ST AUGUSTINE FL
32092-9347
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-8110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS69545
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: