Healthcare Provider Details

I. General information

NPI: 1326324732
Provider Name (Legal Business Name): DR. ANDREA GLENN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2011
Last Update Date: 10/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5640 211TH ST
MATTESON IL
60443-1503
US

IV. Provider business mailing address

7379 WINCHESTER LN
SCHERERVILLE IN
46375-1776
US

V. Phone/Fax

Practice location:
  • Phone: 708-720-2036
  • Fax:
Mailing address:
  • Phone: 708-508-2048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051290366
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: