Provider Demographics
NPI:1770871014
Name:GREENWELL, MARK DAMIAN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DAMIAN
Last Name:GREENWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 TERRACE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ANGIER
Mailing Address - State:NC
Mailing Address - Zip Code:27501-9135
Mailing Address - Country:US
Mailing Address - Phone:919-276-4037
Mailing Address - Fax:
Practice Address - Street 1:13440 NC 210 HIGHWAY
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:NC
Practice Address - Zip Code:27504
Practice Address - Country:US
Practice Address - Phone:919-207-3086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10478183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCBN9778171Medicaid