Healthcare Provider Details

I. General information

NPI: 1619963758
Provider Name (Legal Business Name): GLENN ERIC MARTINEZ BS PHARM, PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JOHN COCHRAN VA MEDICAL CENTER 915 NORTH GRAND
ST. LOUIS MO
63106
US

IV. Provider business mailing address

375 BECKLEY PL
SAINT CHARLES MO
63304-1030
US

V. Phone/Fax

Practice location:
  • Phone: 314-289-6339
  • Fax:
Mailing address:
  • Phone: 636-577-7369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS 39822
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: