MEDICARE: GLENN DANIEL ROBERTS RPH

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	E-07015	MS

General Provider Information

NPI Number	:	1891829677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN DANIEL ROBERTS RPH

Provider Business Mailing Address
First Line	:	PO BOX 217
Second Line	:
City	:	TCHULA
State	:	MS
Zip	:	39169-0217
Country	:	US
Telephone Number	:	662-235-4422
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 MERCER ST
Second Line	:
City	:	TCHULA
State	:	MS
Zip	:	39169
Country	:	US
Telephone Number	:	662-235-4422
Fax Number	:

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

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	05/30/2017

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