Provider Demographics
NPI:1487074183
Name:GREENEVIEW PHARMACY LLC
Entity type:Organization
Organization Name:GREENEVIEW PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:TACKAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-572-1561
Mailing Address - Street 1:4940 COTTONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45335-1522
Mailing Address - Country:US
Mailing Address - Phone:937-675-6500
Mailing Address - Fax:937-675-6540
Practice Address - Street 1:4940 COTTONVILLE RD
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:OH
Practice Address - Zip Code:45335-1522
Practice Address - Country:US
Practice Address - Phone:937-675-6500
Practice Address - Fax:937-675-6540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPMY.022422450-033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0108212Medicaid
2145658OtherPK