Provider Demographics
NPI:1477197531
Name:GREEN LEAF DISPENSARY LLC
Entity Type:Organization
Organization Name:GREEN LEAF DISPENSARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:PECANTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-360-3372
Mailing Address - Street 1:PO BOX 782
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70361-0782
Mailing Address - Country:US
Mailing Address - Phone:985-360-3372
Mailing Address - Fax:985-709-0435
Practice Address - Street 1:6048 W PARK AVE
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70364-1808
Practice Address - Country:US
Practice Address - Phone:985-360-3372
Practice Address - Fax:985-709-0435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy