Provider Demographics
NPI:1083969588
Name:GREEN, NATHANIEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 N GRANADA CIR
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-5706
Mailing Address - Country:US
Mailing Address - Phone:520-229-7196
Mailing Address - Fax:
Practice Address - Street 1:1025 S MILTON RD
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-6349
Practice Address - Country:US
Practice Address - Phone:928-779-9588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS019128183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist