=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295518843
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES MAURITZ GLOMBOWSKI RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2023
-----------------------------------------------------
Last Update Date | 08/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3944 S STRAITS HWY
-----------------------------------------------------
City | INDIAN RIVER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49749-5135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-238-2499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10443 E MUNRO LAKE DR
-----------------------------------------------------
City | LEVERING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49755-8504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-330-7840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302031273
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------