Provider Demographics
NPI:1619195351
Name:JACK W GREENE, DBA
Entity Type:Organization
Organization Name:JACK W GREENE, DBA
Other - Org Name:JEFFERSON COMPOUNDING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER-PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:W
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:865-483-3007
Mailing Address - Street 1:22 N JEFFERSON CIR
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-4805
Mailing Address - Country:US
Mailing Address - Phone:865-483-3007
Mailing Address - Fax:865-483-3071
Practice Address - Street 1:22 N JEFFERSON CIR
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-4805
Practice Address - Country:US
Practice Address - Phone:865-483-3007
Practice Address - Fax:865-483-3071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1122OtherST OF TN BOARD OF PHARMAC
TN4410673OtherNCPDP