Provider Demographics
NPI:1194906875
Name:GREEN, TARA RAE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:RAE
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4635 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-3625
Mailing Address - Country:US
Mailing Address - Phone:812-463-0511
Mailing Address - Fax:812-463-0516
Practice Address - Street 1:4635 1ST AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-3625
Practice Address - Country:US
Practice Address - Phone:812-463-0511
Practice Address - Fax:812-463-0516
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020820A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist