Provider Demographics
NPI:1386153351
Name:GLASGOW, EVANS RAY III
Entity type:Individual
Prefix:
First Name:EVANS
Middle Name:RAY
Last Name:GLASGOW
Suffix:III
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 1:2314 KALISTE SALOOM RD APT 1108
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6836
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4710 JOHNSTON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-4541
Practice Address - Country:US
Practice Address - Phone:337-988-7284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022216183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist