Healthcare Provider Details

I. General information

NPI: 1760855704
Provider Name (Legal Business Name): GLEN ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 TENNIS VILLAGE DR
HEATH TX
75032-5995
US

IV. Provider business mailing address

31 TENNIS VILLAGE DR
HEATH TX
75032-5995
US

V. Phone/Fax

Practice location:
  • Phone: 972-679-9003
  • Fax:
Mailing address:
  • Phone: 972-679-9003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number28458
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number10403
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: