1730435835 NPI number — MRS. SHANNON MARIE GREEN R.PH

Table of content: MRS. SHANNON MARIE GREEN R.PH (NPI 1730435835)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730435835 NPI number — MRS. SHANNON MARIE GREEN R.PH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
SHANNON
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
R.PH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CONWAY
Provider Other First Name:
SHANNON
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730435835
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11900 STAGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AKRON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-863-6850
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
390 W MAIN ST
Provider Second Line Business Practice Location Address:
TOPS MARKETS LLC
Provider Business Practice Location Address City Name:
BATAVIA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-343-9545
Provider Business Practice Location Address Fax Number:
855-331-9042
Provider Enumeration Date:
07/26/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  22743 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)