MEDICARE: GLEN COREY PIERSON R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PH00015079	WA
2	1835P1200X	Pharmacotherapy Pharmacist	PH00015079	WA

General Provider Information

NPI Number	:	1235301383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLEN COREY PIERSON R.PH.

Provider Business Mailing Address
First Line	:	13603 BANDIX RD SE
Second Line	:
City	:	OLALLA
State	:	WA
Zip	:	98359-9469
Country	:	US
Telephone Number	:	253-302-9024
Fax Number	:

Provider Business Practice Location Address
First Line	:	13603 BANDIX RD SE
Second Line	:
City	:	OLALLA
State	:	WA
Zip	:	98359-9469
Country	:	US
Telephone Number	:	253-302-9024
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2008
Last Update Date	:	03/28/2008

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