Provider Demographics
NPI:1699249144
Name:GLASS, ALEXANDER (PHARMD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:GLASS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 LAKE REBEL DR
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-4028
Mailing Address - Country:US
Mailing Address - Phone:706-442-8853
Mailing Address - Fax:
Practice Address - Street 1:2515 CRAWFORD RD
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-3629
Practice Address - Country:US
Practice Address - Phone:334-297-3722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22254183500000X
ALS12398390200000X
GARPH033423183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program