1962417568 NPI number — LEONARD L EDLOE CORP

Table of content: (NPI 1962417568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962417568 NPI number — LEONARD L EDLOE CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEONARD L EDLOE CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EDLOES PROFESSIONAL PHARMACY
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962417568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1124 N 25TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23223-5256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-643-5721
Provider Business Mailing Address Fax Number:
804-644-5301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1124 N 25TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23223-5256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-643-5721
Provider Business Practice Location Address Fax Number:
804-644-5301
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EDLOE
Authorized Official First Name:
LEONARD
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
804-643-5721

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  0201000345 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4804363 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8504750 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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