Healthcare Provider Details

I. General information

NPI: 1235246455
Provider Name (Legal Business Name): GLENN WILSON BOERSTLER BS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 E ELIZABETH AVE
BETHLEHEM PA
18018-6505
US

IV. Provider business mailing address

39 E ELIZABETH AVE
BETHLEHEM PA
18018-6505
US

V. Phone/Fax

Practice location:
  • Phone: 610-866-5037
  • Fax:
Mailing address:
  • Phone: 610-866-5037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP022649L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: