Provider Demographics
NPI:1164726014
Name:GREENE VILLAGE PHARMACY INC
Entity Type:Organization
Organization Name:GREENE VILLAGE PHARMACY INC
Other - Org Name:GREENE VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SCHOMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:207-754-1128
Mailing Address - Street 1:526 ROUTE 202
Mailing Address - Street 2:
Mailing Address - City:GREENE
Mailing Address - State:ME
Mailing Address - Zip Code:04236-4242
Mailing Address - Country:US
Mailing Address - Phone:207-946-2425
Mailing Address - Fax:207-946-2428
Practice Address - Street 1:526 ROUTE 202
Practice Address - Street 2:
Practice Address - City:GREENE
Practice Address - State:ME
Practice Address - Zip Code:04236-4242
Practice Address - Country:US
Practice Address - Phone:207-946-2425
Practice Address - Fax:207-946-2428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPH500014223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1164726014-003Medicaid