Provider Demographics
NPI:1033111968
Name:GLISSON, GARY R (R PH)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:GLISSON
Suffix:
Gender:M
Credentials:R PH
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 400
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27856-0400
Mailing Address - Country:US
Mailing Address - Phone:252-459-2135
Mailing Address - Fax:252-459-9300
Practice Address - Street 1:117 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:NC
Practice Address - Zip Code:27856-1327
Practice Address - Country:US
Practice Address - Phone:252-459-2135
Practice Address - Fax:252-459-9300
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7023183500000X
NC20733332B00000X, 335E00000X, 211D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
No211D00000XPodiatric Medicine & Surgery Service ProvidersAssistant, Podiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC20733OtherBCP-BOARD OF CERTIFICATION IN PEDORTHICS
NC7795227Medicaid