Provider Demographics
NPI:1558689299
Name:GREEN EARTH PHARMACY INC
Entity type:Organization
Organization Name:GREEN EARTH PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BORTELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-613-3856
Mailing Address - Street 1:PO BOX 2361
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72203-2361
Mailing Address - Country:US
Mailing Address - Phone:501-613-3856
Mailing Address - Fax:
Practice Address - Street 1:405 E 3RD ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72201-1611
Practice Address - Country:US
Practice Address - Phone:501-246-3296
Practice Address - Fax:501-246-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-05
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336S0011X
ARAR206283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0423424OtherNCPDP PROVIDER IDENTIFICATION NUMBER