Provider Demographics
NPI:1407136526
Name:GREEN, MARIA
Entity Type:Individual
Prefix:MRS
First Name:MARIA
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 1:22121 SATILLA DR
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-6737
Mailing Address - Country:US
Mailing Address - Phone:704-728-7618
Mailing Address - Fax:
Practice Address - Street 1:19305 W CATAWBA AVE
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-8649
Practice Address - Country:US
Practice Address - Phone:704-896-3691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist