MEDICARE: LEONARD L EDLOE CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy
2	333600000X	Pharmacy	0201000345	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4804363	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962417568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEONARD L EDLOE CORP

Provider Business Mailing Address
First Line	:	1124 N 25TH ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-5256
Country	:	US
Telephone Number	:	804-643-5721
Fax Number	:	804-644-5301

Provider Business Practice Location Address
First Line	:	1124 N 25TH ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-5256
Country	:	US
Telephone Number	:	804-643-5721
Fax Number	:	804-644-5301

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LEONARD L EDLOE
Credential	:	PHARMD
Telephone Number	:	804-643-5721

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	03/27/2008

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