Provider Demographics
NPI:1861775793
Name:POWELL, GLENN (PHARMD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 NIGHT SAIL DR N
Mailing Address - Street 2:APT. 309
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-0006
Mailing Address - Country:US
Mailing Address - Phone:901-491-8112
Mailing Address - Fax:
Practice Address - Street 1:2996 CHURCH RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9825
Practice Address - Country:US
Practice Address - Phone:662-349-4418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-11914183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07487240Medicaid