Healthcare Provider Details

I. General information

NPI: 1962417568
Provider Name (Legal Business Name): LEONARD L EDLOE CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 N 25TH ST
RICHMOND VA
23223-5256
US

IV. Provider business mailing address

1124 N 25TH ST
RICHMOND VA
23223-5256
US

V. Phone/Fax

Practice location:
  • Phone: 804-643-5721
  • Fax: 804-644-5301
Mailing address:
  • Phone: 804-643-5721
  • Fax: 804-644-5301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0201000345
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. LEONARD L EDLOE
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 804-643-5721