MEDICARE: MR. JERRY LEONARD GLOCKE 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	7975040	WI

General Provider Information

NPI Number	:	1306999396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRY LEONARD GLOCKE R.PH.

Provider Business Mailing Address
First Line	:	1119 PINE ST
Second Line	:
City	:	ONALASKA
State	:	WI
Zip	:	54650-2029
Country	:	US
Telephone Number	:	608-519-1181
Fax Number	:	608-775-8578

Provider Business Practice Location Address
First Line	:	2442 STATE RD
Second Line	:
City	:	LA CROSSE
State	:	WI
Zip	:	54601-6155
Country	:	US
Telephone Number	:	608-775-8571
Fax Number	:	608-775-8578

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

Provider Enumeration Date	:	01/21/2007
Last Update Date	:	09/08/2009

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