=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356218333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN WELLNESS RX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2025
-----------------------------------------------------
Last Update Date | 10/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 PEACHTREE INDUSTRIAL BLVD STE 140
-----------------------------------------------------
City | SUWANEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30024-8489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-825-8182
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3479 LILY MAGNOLIA CT
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30519-3858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-825-8182
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SAMIR SHAH
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 706-825-8182
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------