Provider Demographics
NPI:1396843447
Name:GREENE, KEVIN MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:GREENE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 COUNTY ROUTE 65
Mailing Address - Street 2:
Mailing Address - City:BERNHARDS BAY
Mailing Address - State:NY
Mailing Address - Zip Code:13028-3154
Mailing Address - Country:US
Mailing Address - Phone:315-675-8271
Mailing Address - Fax:
Practice Address - Street 1:2 PRESTON ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NY
Practice Address - Zip Code:13316-1216
Practice Address - Country:US
Practice Address - Phone:315-245-1224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044584183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist