Healthcare Provider Details

I. General information

NPI: 1033111968
Provider Name (Legal Business Name): GARY R GLISSON R PH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W CHURCH ST
NASHVILLE NC
27856-1327
US

IV. Provider business mailing address

PO BOX 400
NASHVILLE NC
27856-0400
US

V. Phone/Fax

Practice location:
  • Phone: 252-459-2135
  • Fax: 252-459-9300
Mailing address:
  • Phone: 252-459-2135
  • Fax: 252-459-9300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7023
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number20733
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number20733
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code211D00000X
TaxonomyPodiatric Assistant
License Number20733
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: