Provider Demographics
NPI:1386766202
Name:GREEN, JOHN W (RPH)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
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 1:1221 RUSHRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:IA
Mailing Address - Zip Code:50129-2306
Mailing Address - Country:US
Mailing Address - Phone:515-386-4392
Mailing Address - Fax:
Practice Address - Street 1:1221 RUSHRIDGE RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:IA
Practice Address - Zip Code:50129-2306
Practice Address - Country:US
Practice Address - Phone:515-386-4392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA14357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist