Provider Demographics
NPI:1104140458
Name:GREEN, IRA (RPH)
Entity type:Individual
Prefix:MR
First Name:IRA
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 FAWN HILL RD
Mailing Address - Street 2:
Mailing Address - City:TUXEDO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:10987-3511
Mailing Address - Country:US
Mailing Address - Phone:845-351-2255
Mailing Address - Fax:
Practice Address - Street 1:30 BROTHERHOOD PLAZA DR
Practice Address - Street 2:
Practice Address - City:WASHINGTONVILLE
Practice Address - State:NY
Practice Address - Zip Code:10992-2272
Practice Address - Country:US
Practice Address - Phone:845-351-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23917183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist