Provider Demographics
NPI:1043616964
Name:GREENHAGEN, NICHOLAS JOHN (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOHN
Last Name:GREENHAGEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1191 W KANSAS ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-2281
Mailing Address - Country:US
Mailing Address - Phone:816-781-9347
Mailing Address - Fax:816-781-9492
Practice Address - Street 1:1191 W KANSAS ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-2281
Practice Address - Country:US
Practice Address - Phone:816-781-9347
Practice Address - Fax:816-781-9492
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013026261183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist