1619195351 NPI number — JACK W GREENE, DBA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619195351 NPI number — JACK W GREENE, DBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACK W GREENE, DBA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619195351
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22 N JEFFERSON CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK RIDGE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37830-4805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-483-3007
Provider Business Mailing Address Fax Number:
865-483-3071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 N JEFFERSON CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK RIDGE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37830-4805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-483-3007
Provider Business Practice Location Address Fax Number:
865-483-3071
Provider Enumeration Date:
04/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GREENE
Authorized Official First Name:
JACK
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER-PHARMACIST
Authorized Official Telephone Number:
865-483-3007

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  1122 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1122 . This is a "ST OF TN BOARD OF PHARMAC" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4410673 . This is a "NCPDP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com