Provider Demographics
NPI:1518958347
Name:GREENS PHARMACY INC
Entity Type:Organization
Organization Name:GREENS PHARMACY INC
Other - Org Name:GREENS PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:BSPH
Authorized Official - Phone:419-732-3151
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-0038
Mailing Address - Country:US
Mailing Address - Phone:419-732-3151
Mailing Address - Fax:419-734-6338
Practice Address - Street 1:200 MADISON ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-1947
Practice Address - Country:US
Practice Address - Phone:419-732-3151
Practice Address - Fax:419-734-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHRTP.021068650-033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2059463Medicaid
2072871OtherPK
1228530001Medicare NSC