Healthcare Provider Details

I. General information

NPI: 1134114903
Provider Name (Legal Business Name): GLENN RUSTY REX D.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 2 BOX 247
STROUD OK
74079-9652
US

IV. Provider business mailing address

4202 W 18TH AVE
STILLWATER OK
74074-1603
US

V. Phone/Fax

Practice location:
  • Phone: 918-968-9531
  • Fax: 918-968-0113
Mailing address:
  • Phone: 405-747-8999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8894
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number20503
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: