Provider Demographics
NPI:1073205969
Name:GREEN PHARMACY AND STORE LLC
Entity Type:Organization
Organization Name:GREEN PHARMACY AND STORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BABATUNDE
Authorized Official - Middle Name:ADEDAYO
Authorized Official - Last Name:OSOBU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:267-307-1581
Mailing Address - Street 1:4931 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-2254
Mailing Address - Country:US
Mailing Address - Phone:267-996-8770
Mailing Address - Fax:267-996-8100
Practice Address - Street 1:4931 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-2254
Practice Address - Country:US
Practice Address - Phone:267-996-8770
Practice Address - Fax:267-996-8100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy