Provider Demographics
NPI:1750349833
Name:MILAM, GLENN R
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:R
Last Name:MILAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GLENN
Other - Middle Name:R
Other - Last Name:MILAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:1712 LAUREL GROVE RD
Mailing Address - Street 2:
Mailing Address - City:SUTHERLIN
Mailing Address - State:VA
Mailing Address - Zip Code:24594-3540
Mailing Address - Country:US
Mailing Address - Phone:434-793-5711
Mailing Address - Fax:
Practice Address - Street 1:155 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-2921
Practice Address - Country:US
Practice Address - Phone:434-793-5711
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204690183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist