Provider Demographics
NPI:1104344720
Name:GLIDEWELL, MARKIE COLLINS (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:MARKIE
Middle Name:COLLINS
Last Name:GLIDEWELL
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3014 TINA AVENUE APT 401
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808
Mailing Address - Country:US
Mailing Address - Phone:406-241-6465
Mailing Address - Fax:
Practice Address - Street 1:2527 N RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1313
Practice Address - Country:US
Practice Address - Phone:406-543-1163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-04
Last Update Date:2017-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-46985183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist