Provider Demographics
NPI:1821564311
Name:GREENHOE, CARLY ANASTACIA (PHARMD)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ANASTACIA
Last Name:GREENHOE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12713 3 MILE RD NE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-9456
Mailing Address - Country:US
Mailing Address - Phone:616-490-2722
Mailing Address - Fax:
Practice Address - Street 1:08337 M 140 STE 2
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-1990
Practice Address - Country:US
Practice Address - Phone:269-637-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302047222183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist