MEDICARE: MR. GLENN EIJI NAMURA

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	14740	AZ

General Provider Information

NPI Number	:	1487955613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GLENN EIJI NAMURA

Provider Business Mailing Address
First Line	:	3743 WESTCLIFF
Second Line	:
City	:	LAUGHLIN
State	:	NV
Zip	:	89028
Country	:	US
Telephone Number	:	702-299-9393
Fax Number	:

Provider Business Practice Location Address
First Line	:	1751 HIGHWAY 95
Second Line	:
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-6902
Country	:	US
Telephone Number	:	928-763-1888
Fax Number	:

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

Provider Enumeration Date	:	11/04/2010
Last Update Date	:	11/04/2010

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