Provider Demographics
NPI:1831254994
Name:GREENFIELD PHARMS, LLC
Entity type:Organization
Organization Name:GREENFIELD PHARMS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:731-618-1787
Mailing Address - Street 1:116 E COLLEGE
Mailing Address - Street 2:
Mailing Address - City:KENTON
Mailing Address - State:TN
Mailing Address - Zip Code:38233
Mailing Address - Country:US
Mailing Address - Phone:731-749-5951
Mailing Address - Fax:731-749-5135
Practice Address - Street 1:116 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:KENTON
Practice Address - State:TN
Practice Address - Zip Code:38233-1336
Practice Address - Country:US
Practice Address - Phone:731-749-5951
Practice Address - Fax:731-749-5135
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREENFIELD PHARMS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-27
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TN4923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ035672Medicaid
2095603OtherPK
TN9440412Medicaid