Healthcare Provider Details

I. General information

NPI: 1285671750
Provider Name (Legal Business Name): GREEN WAVE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 MCCLURE AVE
CLINTWOOD VA
24228-6845
US

IV. Provider business mailing address

165 MCCLURE AVE PO BOX 1310
CLINTWOOD VA
24228-6845
US

V. Phone/Fax

Practice location:
  • Phone: 276-926-4733
  • Fax: 276-926-5137
Mailing address:
  • Phone: 276-926-4733
  • Fax: 276-926-5137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0201002056
License Number StateVA

VIII. Authorized Official

Name: MRS. SHERYL DAWN PIENTKA
Title or Position: PHARMACIST IN CHARGE
Credential: RPH
Phone: 276-926-4733