Healthcare Provider Details

I. General information

NPI: 1669642922
Provider Name (Legal Business Name): GLENDALE PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12444 WARWICK BLVD
NEWPORT NEWS VA
23606-3042
US

IV. Provider business mailing address

12444 WARWICK BLVD
NEWPORT NEWS VA
23606-3042
US

V. Phone/Fax

Practice location:
  • Phone: 757-595-3355
  • Fax: 757-596-1863
Mailing address:
  • Phone: 757-595-3355
  • Fax: 757-596-1863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0201002006
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0201002006
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number0201002006
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number0201002006
License Number StateVA

VIII. Authorized Official

Name: MR. ARMYA R MARAE
Title or Position: PHARMACIST/OWNER
Credential: RPH
Phone: 757-595-3355