Basic Information
| Provider Information | |||||||||
| NPI: | 1093818429 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLENDALE CLINIC PHARMACY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9233 N GREEN BAY RD | ||||||||
| Address2: | |||||||||
| City: | BROWN DEER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143629560 | ||||||||
| FaxNumber: | 4142708140 | ||||||||
| Practice Location | |||||||||
| Address1: | 9233 N GREEN BAY RD | ||||||||
| Address2: | |||||||||
| City: | BROWN DEER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143629560 | ||||||||
| FaxNumber: | 4142708140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DALAL | ||||||||
| AuthorizedOfficialFirstName: | EMILE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHARMACIST OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4143629560 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RPH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 33143100 | 05 | WI | MEDICAID |