Provider Demographics
NPI:1912930926
Name:GREENE COUNTY DRUG STORE LLC
Entity Type:Organization
Organization Name:GREENE COUNTY DRUG STORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BENJIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:423-638-7101
Mailing Address - Street 1:906 TUSCULUM BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-4004
Mailing Address - Country:US
Mailing Address - Phone:423-638-7101
Mailing Address - Fax:423-638-9105
Practice Address - Street 1:906 TUSCULUM BLVD
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4004
Practice Address - Country:US
Practice Address - Phone:423-638-7101
Practice Address - Fax:423-638-9105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454457Medicaid
TN5013580001Medicare ID - Type UnspecifiedPROVIDER #