Provider Demographics
NPI:1104862135
Name:GREEN VALLEY PHARMACY
Entity Type:Organization
Organization Name:GREEN VALLEY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:SHRADER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:301-371-7835
Mailing Address - Street 1:11791 FINGERBOARD RD
Mailing Address - Street 2:SUITE 16
Mailing Address - City:MONROVIA
Mailing Address - State:MD
Mailing Address - Zip Code:21770-9263
Mailing Address - Country:US
Mailing Address - Phone:301-865-2200
Mailing Address - Fax:301-865-2212
Practice Address - Street 1:11791 FINGERBOARD RD
Practice Address - Street 2:SUITE 16
Practice Address - City:MONROVIA
Practice Address - State:MD
Practice Address - Zip Code:21770-9263
Practice Address - Country:US
Practice Address - Phone:301-865-2200
Practice Address - Fax:301-865-2212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDPO31483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2127199OtherNABP
MDBG8615013OtherDEA NUMBER
MD=========OtherEIN