Provider Demographics
NPI:1609865773
Name:GREENWAY MEDICAL INC.
Entity Type:Organization
Organization Name:GREENWAY MEDICAL INC.
Other - Org Name:DIABETES SOURCE RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-267-7470
Mailing Address - Street 1:PO BOX 52884
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-2884
Mailing Address - Country:US
Mailing Address - Phone:337-267-7470
Mailing Address - Fax:866-794-5729
Practice Address - Street 1:803 COOLIDGE BLVD
Practice Address - Street 2:SUITE 128
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2376
Practice Address - Country:US
Practice Address - Phone:337-267-7470
Practice Address - Fax:866-794-5729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX011633701Medicaid
LAG9723OtherBCBS OF LOUISIANA
TX010164401Medicaid
LA1467537Medicaid
TX519779OtherBCBS OF TEXAS
TX010164401Medicaid