Provider Demographics
NPI:1366725368
Name:BALAS, GLENN S
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:S
Last Name:BALAS
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 1:2320 S WENTWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2014
Mailing Address - Country:US
Mailing Address - Phone:312-842-2500
Mailing Address - Fax:312-842-1013
Practice Address - Street 1:2320 S WENTWORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2014
Practice Address - Country:US
Practice Address - Phone:312-842-2500
Practice Address - Fax:312-842-1013
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051028948183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist