Healthcare Provider Details

I. General information

NPI: 1124500160
Provider Name (Legal Business Name): LYNETTE R GLOCKNER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10858 BUCKLEY HALL ROAD
MATHEWS VA
23109
US

IV. Provider business mailing address

11451 COVESIDE PT
GLOUCESTER VA
23061-2576
US

V. Phone/Fax

Practice location:
  • Phone: 804-725-2556
  • Fax: 804-725-0786
Mailing address:
  • Phone: 330-221-7450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MRS. LYNETTE RENAE GLOCKNER
Title or Position: OWNER/PHARMACIST
Credential: RPH
Phone: 330-221-7450