Provider Demographics
NPI:1154664191
Name:GREEN COUNTRY RX LLC
Entity type:Organization
Organization Name:GREEN COUNTRY RX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-406-6703
Mailing Address - Street 1:700 N LYNN RIGGS BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-5623
Mailing Address - Country:US
Mailing Address - Phone:918-342-8050
Mailing Address - Fax:918-342-8099
Practice Address - Street 1:700 N LYNN RIGGS BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-5623
Practice Address - Country:US
Practice Address - Phone:918-342-8050
Practice Address - Fax:918-342-8099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-28
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29-62133336C0003X
3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139596OtherPK
OK200486060AMedicaid