Provider Demographics
NPI:1417557489
Name:GREEN, WILLIAM ROBERT JR (RPH)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ROBERT
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MARKET PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30121-2236
Mailing Address - Country:US
Mailing Address - Phone:770-386-7582
Mailing Address - Fax:770-386-4571
Practice Address - Street 1:101 MARKET PLACE BLVD
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121-2236
Practice Address - Country:US
Practice Address - Phone:770-386-7582
Practice Address - Fax:770-386-4571
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH016242183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty