Provider Demographics
NPI:1720677933
Name:GREENE, GAYLA
Entity type:Individual
Prefix:
First Name:GAYLA
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 MAXWELL ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-1231
Mailing Address - Country:US
Mailing Address - Phone:217-273-9697
Mailing Address - Fax:
Practice Address - Street 1:245 W 1ST DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5299
Practice Address - Country:US
Practice Address - Phone:217-429-5165
Practice Address - Fax:217-429-5172
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051036441183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist