Provider Demographics
NPI:1982834131
Name:VALLEY LAKE INC
Entity Type:Organization
Organization Name:VALLEY LAKE INC
Other - Org Name:GREEN VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:AKUWUDIKE
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ANOZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-565-3374
Mailing Address - Street 1:2245 N GREEN VALLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-5024
Mailing Address - Country:US
Mailing Address - Phone:702-565-3374
Mailing Address - Fax:702-565-3377
Practice Address - Street 1:2245 N GREEN VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-5024
Practice Address - Country:US
Practice Address - Phone:702-565-3374
Practice Address - Fax:702-565-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPH037813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2121178OtherPK