Healthcare Provider Details

I. General information

NPI: 1235301383
Provider Name (Legal Business Name): GLEN COREY PIERSON R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13603 BANDIX RD SE
OLALLA WA
98359-9469
US

IV. Provider business mailing address

13603 BANDIX RD SE
OLALLA WA
98359-9469
US

V. Phone/Fax

Practice location:
  • Phone: 253-302-9024
  • Fax:
Mailing address:
  • Phone: 253-302-9024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00015079
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPH00015079
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: