Provider Demographics
NPI:1528484631
Name:GREENHAVEN PHARMACY
Entity type:Organization
Organization Name:GREENHAVEN PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EDDY
Authorized Official - Middle Name:C
Authorized Official - Last Name:PON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:916-290-6639
Mailing Address - Street 1:7248 S LAND PARK DR STE 116
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-3661
Mailing Address - Country:US
Mailing Address - Phone:916-378-5757
Mailing Address - Fax:916-290-6639
Practice Address - Street 1:7248 S LAND PARK DR STE 116
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-3661
Practice Address - Country:US
Practice Address - Phone:916-378-5757
Practice Address - Fax:916-290-6639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY51814333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy