1104862135 NPI number — GREEN VALLEY PHARMACY

Table of content: (NPI 1104862135)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104862135 NPI number — GREEN VALLEY PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREEN VALLEY PHARMACY
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:
Provider Other Organization Name Type Code:
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:
1104862135
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11791 FINGERBOARD RD
Provider Second Line Business Mailing Address:
SUITE 16
Provider Business Mailing Address City Name:
MONROVIA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21770-9263
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-865-2200
Provider Business Mailing Address Fax Number:
301-865-2212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11791 FINGERBOARD RD
Provider Second Line Business Practice Location Address:
SUITE 16
Provider Business Practice Location Address City Name:
MONROVIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21770-9263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-865-2200
Provider Business Practice Location Address Fax Number:
301-865-2212
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHRADER
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST/OWNER
Authorized Official Telephone Number:
301-371-7835

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PO3148 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2127199 . This is a "NABP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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