Healthcare Provider Details

I. General information

NPI: 1245332030
Provider Name (Legal Business Name): RONALD SHANE GREENE PHARMD, BCPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 JEROME ST STE 400
FORT WORTH TX
76104-3942
US

IV. Provider business mailing address

1714 MCGARRY LN
MANSFIELD TX
76063-7926
US

V. Phone/Fax

Practice location:
  • Phone: 817-732-6060
  • Fax: 817-731-2541
Mailing address:
  • Phone: 817-437-5539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number38587
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number38587
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: