Provider Demographics
NPI:1497078042
Name:GREEN, GLENN J JR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:J
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 WICHERS DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3041
Mailing Address - Country:US
Mailing Address - Phone:504-390-9135
Mailing Address - Fax:
Practice Address - Street 1:12A WESTBANK EXPY STE 101
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-3659
Practice Address - Country:US
Practice Address - Phone:504-509-5442
Practice Address - Fax:504-509-5421
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45045183500000X
LA17753183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1896870Medicaid
LAMA.000101OtherMEDICATION ADMINISTRATION