Healthcare Provider Details

I. General information

NPI: 1003827502
Provider Name (Legal Business Name): GLENWOOD PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 08/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13040 HIGHWAY 12
OROFINO ID
83544-9330
US

IV. Provider business mailing address

1105 MICHIGAN AVE
OROFINO ID
83544-9005
US

V. Phone/Fax

Practice location:
  • Phone: 208-476-0329
  • Fax: 208-476-0349
Mailing address:
  • Phone: 208-476-0329
  • Fax: 208-476-0349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number19201RP
License Number StateID

VIII. Authorized Official

Name: PATRICIA PETERSON
Title or Position: PRESIDENT
Credential:
Phone: 208-476-5727