MEDICARE: GLEN ED PHARMACY LLC

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	3336C0004X	Compounding Pharmacy
2	3336L0003X	Long Term Care Pharmacy
3	3336C0003X	Community/Retail Pharmacy	054.018063	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1484308	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1699092122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLEN ED PHARMACY LLC

Provider Business Mailing Address
First Line	:	1 GINGER CREEK MDWS
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-3508
Country	:	US
Telephone Number	:	618-655-9898
Fax Number	:	618-655-0230

Provider Business Practice Location Address
First Line	:	1 GINGER CREEK MDWS
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-3508
Country	:	US
Telephone Number	:	618-655-9898
Fax Number	:	618-655-0230

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID RIECK
Credential	:
Telephone Number	:	314-542-0022

Provider Enumeration Date	:	04/23/2010
Last Update Date	:	03/12/2013

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