Healthcare Provider Details

I. General information

NPI: 1699092122
Provider Name (Legal Business Name): GLEN ED PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GINGER CREEK MDWS
GLEN CARBON IL
62034-3508
US

IV. Provider business mailing address

1 GINGER CREEK MDWS
GLEN CARBON IL
62034-3508
US

V. Phone/Fax

Practice location:
  • Phone: 618-655-9898
  • Fax: 618-655-0230
Mailing address:
  • Phone: 618-655-9898
  • Fax: 618-655-0230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054.018063
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DAVID RIECK
Title or Position: OWNER
Credential:
Phone: 314-542-0022