Healthcare Provider Details

I. General information

NPI: 1154284388
Provider Name (Legal Business Name): MANDERRIOUS L GLENN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 AUSTELL RD
AUSTELL GA
30106-1121
US

IV. Provider business mailing address

723 ARBOR HILL DR
STONE MOUNTAIN GA
30088-2363
US

V. Phone/Fax

Practice location:
  • Phone: 770-732-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberRPH035275
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: