Provider Demographics
NPI:1558886077
Name:GREEN, REGINALD EUGENE JR
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:EUGENE
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 FOUNDERS BAY RD
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-8089
Mailing Address - Country:US
Mailing Address - Phone:843-651-8863
Mailing Address - Fax:843-651-8864
Practice Address - Street 1:101 FOUNDERS BAY RD
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-8089
Practice Address - Country:US
Practice Address - Phone:843-651-8863
Practice Address - Fax:843-651-8864
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37301183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist