MEDICARE: GLENWOOD PHARMACY, INC

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	333600000X	Pharmacy	2006CP	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1303495	OTHER	NABP

General Provider Information

NPI Number	:	1386640001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENWOOD PHARMACY, INC

Provider Business Mailing Address
First Line	:	1105 MICHIGAN AVE
Second Line	:
City	:	OROFINO
State	:	ID
Zip	:	83544-9005
Country	:	US
Telephone Number	:	208-476-5727
Fax Number	:	208-476-4045

Provider Business Practice Location Address
First Line	:	1105 MICHIGAN AVE
Second Line	:
City	:	OROFINO
State	:	ID
Zip	:	83544-9005
Country	:	US
Telephone Number	:	208-476-5727
Fax Number	:	208-476-4045

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PATRICIA PETERSON
Credential	:
Telephone Number	:	208-476-5727

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	07/15/2013

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Directions to “GLENWOOD PHARMACY, INC ” Practice Location

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