Provider Demographics
NPI:1104912526
Name:GREEN, MARSHA JEAN (RPH)
Entity type:Individual
Prefix:MRS
First Name:MARSHA
Middle Name:JEAN
Last Name:GREEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 SPEIGHT AVE. #214
Mailing Address - Street 2:MCLANE STUDENT LIFE COMPLEX - PHARMACY
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76706
Mailing Address - Country:US
Mailing Address - Phone:254-710-4428
Mailing Address - Fax:254-710-3620
Practice Address - Street 1:209 SPEIGHT AVE. #214
Practice Address - Street 2:MCLANE STUDENT LIFE COMPLEX - PHARMACY
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76706
Practice Address - Country:US
Practice Address - Phone:254-710-4428
Practice Address - Fax:254-710-3620
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27663183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX27663OtherTEXAS RPH LICENSE NUMBER