Provider Demographics
NPI:1104170877
Name:GLENNON, MARCIA (RPH)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:GLENNON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1927 WALLINFORD CIR
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-3501
Mailing Address - Country:US
Mailing Address - Phone:608-837-9377
Mailing Address - Fax:608-849-7999
Practice Address - Street 1:233 S CENTURY AVE
Practice Address - Street 2:
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53597-1249
Practice Address - Country:US
Practice Address - Phone:608-849-7888
Practice Address - Fax:608-849-7999
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11574-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist