Provider Demographics
NPI:1477697167
Name:GREENE PHARMACY
Entity Type:Organization
Organization Name:GREENE PHARMACY
Other - Org Name:GREENE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:BACH OF SCIENCE
Authorized Official - Phone:573-695-4533
Mailing Address - Street 1:128 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STEELE
Mailing Address - State:MO
Mailing Address - Zip Code:63877-1434
Mailing Address - Country:US
Mailing Address - Phone:573-695-4533
Mailing Address - Fax:573-695-3327
Practice Address - Street 1:128 W MAIN ST
Practice Address - Street 2:
Practice Address - City:STEELE
Practice Address - State:MO
Practice Address - Zip Code:63877-1434
Practice Address - Country:US
Practice Address - Phone:573-695-4533
Practice Address - Fax:573-695-3327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MO0038503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2049643OtherPK
MO621294404Medicaid
0144610001Medicare NSC