Basic Information
| Provider Information | |||||||||
| NPI: | 1245221068 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREEN TREE PHARMACY, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GREEN TREE PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 W JEFFERSON ST | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617013946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098284361 | ||||||||
| FaxNumber: | 3098299512 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 CAROLYN DR | ||||||||
| Address2: | |||||||||
| City: | MINONK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094323451 | ||||||||
| FaxNumber: | 3094322575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2005 | ||||||||
| LastUpdateDate: | 06/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | ATER | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | EXEC. VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 3098284361 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 032-006965 | IL | N | Suppliers | Pharmacy | 3336L0003X | 058-013453 | IL | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336S0011X | 058-013453 | IL | N | Suppliers | Pharmacy | Specialty Pharmacy | 333600000X | 058-013453 | IL | Y | Suppliers | Pharmacy |
No ID Information.