Basic Information
| Provider Information | |||||||||
| NPI: | 1871119560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | DEVON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6234 W BEHREND DR APT 2134 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853086916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743234727 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9600 N METRO PKWY W | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850511402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803370256 | ||||||||
| FaxNumber: | 4803370257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2020 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | S024613 | AZ | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.