Provider Demographics
NPI:1043518566
Name:HANSON, GLENN M
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:M
Last Name:HANSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 S MCKENZIE ST
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535-1818
Mailing Address - Country:US
Mailing Address - Phone:251-971-1017
Mailing Address - Fax:
Practice Address - Street 1:1255 S MCKENZIE ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-1818
Practice Address - Country:US
Practice Address - Phone:850-462-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2015-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS49955183500000X
VA0202213262183500000X
GARPH025135183500000X
AL17958183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist