Provider Demographics
NPI:1538499900
Name:GREEN, TERRY MAC (RPH)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:MAC
Last Name:GREEN
Suffix:
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 1:16100 SW 72ND
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97224
Mailing Address - Country:US
Mailing Address - Phone:503-372-1700
Mailing Address - Fax:
Practice Address - Street 1:16100 SW 72ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97224-7745
Practice Address - Country:US
Practice Address - Phone:503-372-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-07
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR53961835G0303X
WA146171835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric