Provider Demographics
NPI:1649229378
Name:LEONARD MUSE TRADING AS GREEN VALLEY PHARMACY
Entity Type:Organization
Organization Name:LEONARD MUSE TRADING AS GREEN VALLEY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:703-979-1441
Mailing Address - Street 1:2415 S SHIRLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22206-2524
Mailing Address - Country:US
Mailing Address - Phone:703-979-1441
Mailing Address - Fax:703-553-4846
Practice Address - Street 1:2415 S SHIRLINGTON RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22206-2524
Practice Address - Country:US
Practice Address - Phone:703-979-1441
Practice Address - Fax:703-553-4846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201000328183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008504997Medicaid
VA4804818OtherNATIONAL PHARMACY ID
VA008504997Medicaid