Provider Demographics
NPI:1487955613
Name:NAMURA, GLENN EIJI
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:EIJI
Last Name:NAMURA
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 1:3743 WESTCLIFF
Mailing Address - Street 2:
Mailing Address - City:LAUGHLIN
Mailing Address - State:NV
Mailing Address - Zip Code:89028
Mailing Address - Country:US
Mailing Address - Phone:702-299-9393
Mailing Address - Fax:
Practice Address - Street 1:1751 HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-6902
Practice Address - Country:US
Practice Address - Phone:928-763-1888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14740183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist