Provider Demographics
NPI:1023218138
Name:R P GLIDDEN INC
Entity type:Organization
Organization Name:R P GLIDDEN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:GUSTAVSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-492-2919
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:SCHOOLCRAFT
Mailing Address - State:MI
Mailing Address - Zip Code:49087-0399
Mailing Address - Country:US
Mailing Address - Phone:269-679-2008
Mailing Address - Fax:269-679-2722
Practice Address - Street 1:139 N GRAND ST
Practice Address - Street 2:
Practice Address - City:SCHOOLCRAFT
Practice Address - State:MI
Practice Address - Zip Code:49087-5111
Practice Address - Country:US
Practice Address - Phone:269-679-2008
Practice Address - Fax:269-679-2722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301008669332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2370081OtherNCPDP
MI87-5199549Medicaid
MI5967900001Medicare NSC