Provider Demographics
NPI:1194199182
Name:ANTLE, GLENN ROY
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ROY
Last Name:ANTLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 SPINNAKER
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-2942
Mailing Address - Country:US
Mailing Address - Phone:954-218-5584
Mailing Address - Fax:
Practice Address - Street 1:586 SPINNAKER
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-2942
Practice Address - Country:US
Practice Address - Phone:954-218-5584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-14
Last Update Date:2015-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39027183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist