Provider Demographics
NPI:1376801753
Name:GREEN, RUSSELL FRANKLIN (BS)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:FRANKLIN
Last Name:GREEN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 S CARAWAY RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-6205
Mailing Address - Country:US
Mailing Address - Phone:870-972-8751
Mailing Address - Fax:870-972-1285
Practice Address - Street 1:2308 S CARAWAY RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6205
Practice Address - Country:US
Practice Address - Phone:870-972-8751
Practice Address - Fax:870-972-1285
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD06430183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist