1497078042 NPI number — DR. GLENN J GREEN JR. PHARMD

Table of content: DR. GLENN J GREEN JR. PHARMD (NPI 1497078042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497078042 NPI number — DR. GLENN J GREEN JR. PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
GLENN
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497078042
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4700 WICHERS DR
Provider Second Line Business Mailing Address:
SUITE 303
Provider Business Mailing Address City Name:
MARRERO
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70072-3041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-390-9135
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12A WESTBANK EXPY STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRETNA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70053-3659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-509-5442
Provider Business Practice Location Address Fax Number:
504-509-5421
Provider Enumeration Date:
03/10/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  45045 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183500000X , with the licence number: 17753 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1896870 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: MA.000101 . This is a "MEDICATION ADMINISTRATION" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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