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General NPI Number Information
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NPI Number | 1477197531
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Entity Type | Organization
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Legal Business Name | GREEN LEAF DISPENSARY LLC
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Dates
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Enumeration Date | 11/01/2019
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Last Update Date | 11/01/2019
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Provider Practice Location Address
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Address Line | 6048 W PARK AVE
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City | HOUMA
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State | LA
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Zip | 70364-1808
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Country | US
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Telephone | 985-360-3372
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Fax | 985-709-0435
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Provider Business Mailing Address
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Address Line | PO BOX 782
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City | HOUMA
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State | LA
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Zip | 70361-0782
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Country | US
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Telephone | 985-360-3372
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Fax | 985-709-0435
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Authorized Official
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Title or Position | PRESIDENT
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Name | OMAR PECANTTE
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Credential |
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Telephone | 985-360-3372
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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