Healthcare Provider Details

I. General information

NPI: 1306981436
Provider Name (Legal Business Name): GREEN VALLEY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11791 FINGERBOARD RD
MONROVIA MD
21770-9263
US

IV. Provider business mailing address

11791 FINGERBOARD RD
MONROVIA MD
21770-9263
US

V. Phone/Fax

Practice location:
  • Phone: 301-865-2200
  • Fax: 301-865-2212
Mailing address:
  • Phone:
  • Fax: 301-865-2212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPO03148
License Number StateMD

VIII. Authorized Official

Name: MR. LEON J MICAN JR.
Title or Position: OWNER
Credential:
Phone: 301-865-2200