Provider Demographics
NPI:1174863344
Name:GREENSBURG FAMILY PHARMACY LLC
Entity type:Organization
Organization Name:GREENSBURG FAMILY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TINNERELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-320-5175
Mailing Address - Street 1:1812 W THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-2945
Mailing Address - Country:US
Mailing Address - Phone:985-345-4767
Mailing Address - Fax:985-345-4768
Practice Address - Street 1:6166 HWY 10
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:LA
Practice Address - Zip Code:70441
Practice Address - Country:US
Practice Address - Phone:225-222-4279
Practice Address - Fax:225-222-4043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-25
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY.006667-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139160OtherPK
LA2201930Medicaid