Provider Demographics
NPI:1871964569
Name:HERSKOWITZ, GLENN (PHARM)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:HERSKOWITZ
Suffix:
Gender:M
Credentials:PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5155
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94977-5155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 37TH AVE FL 3
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-4324
Practice Address - Country:US
Practice Address - Phone:650-573-2296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2024-11-14
Deactivation Date:2019-04-01
Deactivation Code:
Reactivation Date:2024-11-14
Provider Licenses
StateLicense IDTaxonomies
NV9078183500000X
CA38475183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist