=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083755243
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL SHANE GREENE PHARM. D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20381 ARCH ST
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72206-9218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-888-2830
-----------------------------------------------------
Fax | 501-888-3118
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9045 MARS HILL RD
-----------------------------------------------------
City | BAUXITE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72011-9162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-258-2316
-----------------------------------------------------
Fax | 501-888-3118
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PD09762
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------