Provider Demographics
NPI:1104107184
Name:SHRADER, GLENN JOHN III (PHARM D)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:JOHN
Last Name:SHRADER
Suffix:III
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15504 BLUE MESA DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-8848
Mailing Address - Country:US
Mailing Address - Phone:405-850-4837
Mailing Address - Fax:
Practice Address - Street 1:2345 N CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-5804
Practice Address - Country:US
Practice Address - Phone:405-521-0924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14889183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist