Provider Demographics
NPI:1083755243
Name:GREENE, MICHAEL SHANE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHANE
Last Name:GREENE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9045 MARS HILL RD
Mailing Address - Street 2:
Mailing Address - City:BAUXITE
Mailing Address - State:AR
Mailing Address - Zip Code:72011-9162
Mailing Address - Country:US
Mailing Address - Phone:501-258-2316
Mailing Address - Fax:501-888-3118
Practice Address - Street 1:20381 ARCH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72206-9218
Practice Address - Country:US
Practice Address - Phone:501-888-2830
Practice Address - Fax:501-888-3118
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD09762183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist