Provider Demographics
NPI:1386282770
Name:GREEN, DAVID (PHARMD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
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 1:725 POLE LINE RD W
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5860
Mailing Address - Country:US
Mailing Address - Phone:208-814-1655
Mailing Address - Fax:208-814-1917
Practice Address - Street 1:725 POLE LINE RD W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5860
Practice Address - Country:US
Practice Address - Phone:208-814-1655
Practice Address - Fax:208-814-1917
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0116011835X0200X
IDP55581835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology