Provider Demographics
NPI:1164554721
Name:GREEN, JUDY VOGT (RPH)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:VOGT
Last Name:GREEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 CONCORDIA AVE
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-2679
Mailing Address - Country:US
Mailing Address - Phone:318-336-8999
Mailing Address - Fax:318-757-4106
Practice Address - Street 1:114 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:FERRIDAY
Practice Address - State:LA
Practice Address - Zip Code:71334-2826
Practice Address - Country:US
Practice Address - Phone:318-757-3811
Practice Address - Fax:318-757-4106
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10208183500000X
MSR-05857183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1261289Medicaid
LA1261289Medicaid