Provider Demographics
NPI:1861789349
Name:BALIAN, GLENN NAZARETH (RPH, PHARMD, MBA)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:NAZARETH
Last Name:BALIAN
Suffix:
Gender:M
Credentials:RPH, PHARMD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 COMMONWEALTH RD
Mailing Address - Street 2:APARTMENT 2
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-1318
Mailing Address - Country:US
Mailing Address - Phone:617-678-3515
Mailing Address - Fax:
Practice Address - Street 1:150 S HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-4817
Practice Address - Country:US
Practice Address - Phone:857-364-4309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH233397183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPH233397OtherMASSACHUSETTS PHARMACY LICENSE