Provider Demographics
NPI:1083390652
Name:GREEN, JEFFRY LEE (RPH)
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:LEE
Last Name:GREEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 ROCK CHALK DR APT 23308
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-5168
Mailing Address - Country:US
Mailing Address - Phone:704-677-0693
Mailing Address - Fax:
Practice Address - Street 1:4690 SHADYSIDE LN
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-4400
Practice Address - Country:US
Practice Address - Phone:704-677-0693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist