Provider Demographics
NPI:1154415560
Name:GREEN SPECIALTY PHARMACY
Entity type:Organization
Organization Name:GREEN SPECIALTY PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANISH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:810-230-9900
Mailing Address - Street 1:G3333 BEECHER RD # B
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3619
Mailing Address - Country:US
Mailing Address - Phone:810-230-9900
Mailing Address - Fax:810-230-9988
Practice Address - Street 1:G3333 BEECHER RD
Practice Address - Street 2:B
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3619
Practice Address - Country:US
Practice Address - Phone:810-230-9900
Practice Address - Fax:810-230-9988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010088923336C0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2368858OtherOTHER ID NUMBER
2368858OtherOTHER ID NUMBER-COMMERCIAL NUMBER