Provider Demographics
NPI:1275833048
Name:GREEN, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5188 KYLE CENTER DR
Mailing Address - Street 2:T-2725
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-6137
Mailing Address - Country:US
Mailing Address - Phone:512-268-7551
Mailing Address - Fax:512-268-7551
Practice Address - Street 1:5188 KYLE CENTER DR
Practice Address - Street 2:T-2725
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6137
Practice Address - Country:US
Practice Address - Phone:512-268-7551
Practice Address - Fax:512-268-7551
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-27
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34854183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist