Provider Demographics
NPI:1225582760
Name:GREEN, JUSTIN TYLER (PHARMD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TYLER
Last Name:GREEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9815 ROSE COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-3334
Mailing Address - Country:US
Mailing Address - Phone:704-948-4806
Mailing Address - Fax:704-464-3234
Practice Address - Street 1:9815 ROSE COMMONS DR
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-3334
Practice Address - Country:US
Practice Address - Phone:704-948-4806
Practice Address - Fax:704-464-3234
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-13
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26444183500000X
SC36767183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist