Basic Information
| Provider Information | |||||||||
| NPI: | 1770558371 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPH, CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3715 91ST AVENUE CT E | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983712214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534685566 | ||||||||
| FaxNumber: | 2539683349 | ||||||||
| Practice Location | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682607 | ||||||||
| FaxNumber: | 2539683349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0018X | 013254 | LA | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
No ID Information.