Provider Demographics
NPI:1316261613
Name:GREEN, RICHARD DALE (RPH)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:DALE
Last Name:GREEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 MILES RD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-2119
Mailing Address - Country:US
Mailing Address - Phone:936-824-3337
Mailing Address - Fax:
Practice Address - Street 1:3061 S JOHN REDDITT DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-5603
Practice Address - Country:US
Practice Address - Phone:936-632-5566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21556183500000X
AK892183500000X
OR7471183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist