Provider Demographics
NPI:1497038897
Name:GREEN, HEATHER A (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-1915
Mailing Address - Country:US
Mailing Address - Phone:850-994-1363
Mailing Address - Fax:850-994-2326
Practice Address - Street 1:3909 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1915
Practice Address - Country:US
Practice Address - Phone:850-994-1363
Practice Address - Fax:850-994-2326
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS41439183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist