Provider Demographics
NPI:1700375318
Name:GREEN HEALTH INTEGRATIVE & WELLNESS PHARMACY
Entity Type:Organization
Organization Name:GREEN HEALTH INTEGRATIVE & WELLNESS PHARMACY
Other - Org Name:GREEN HEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/MANAGING PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:KWAME
Authorized Official - Middle Name:BINFO
Authorized Official - Last Name:ENNIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:703-499-2373
Mailing Address - Street 1:6047 TICKET WAY
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-6138
Mailing Address - Country:US
Mailing Address - Phone:703-499-2373
Mailing Address - Fax:
Practice Address - Street 1:2898 DALE BLVD UNIT 105
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-1118
Practice Address - Country:US
Practice Address - Phone:703-499-2373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy