Provider Demographics
NPI:1063680767
Name:GREEN, THOMAS RICHARD
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:RICHARD
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 NEW SCOTLAND RD
Mailing Address - Street 2:
Mailing Address - City:SLINGERLANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12159
Mailing Address - Country:US
Mailing Address - Phone:518-478-0597
Mailing Address - Fax:518-478-0471
Practice Address - Street 1:1395 NEW SCOTLAND RD
Practice Address - Street 2:
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159
Practice Address - Country:US
Practice Address - Phone:518-478-0597
Practice Address - Fax:518-478-0471
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048138183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01472893Medicaid
NY0525250312Medicare NSC