Provider Demographics
NPI:1669642922
Name:GLENDALE PHARMACY, LLC
Entity Type:Organization
Organization Name:GLENDALE PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ARMYA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARAE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:757-595-3355
Mailing Address - Street 1:12444 WARWICK BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-3042
Mailing Address - Country:US
Mailing Address - Phone:757-595-3355
Mailing Address - Fax:757-596-1863
Practice Address - Street 1:12444 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3042
Practice Address - Country:US
Practice Address - Phone:757-595-3355
Practice Address - Fax:757-596-1863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201002006332B00000X, 3336C0003X, 3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008514305Medicaid
VA009123610Medicaid
VA7731440001Medicaid