Provider Demographics
NPI:1598357030
Name:GREEN, BRYAN L (DPH)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:L
Last Name:GREEN
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 887
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033-0887
Mailing Address - Country:US
Mailing Address - Phone:918-322-3667
Mailing Address - Fax:918-322-5923
Practice Address - Street 1:262 E 141ST ST
Practice Address - Street 2:
Practice Address - City:GLENPOOL
Practice Address - State:OK
Practice Address - Zip Code:74033-3569
Practice Address - Country:US
Practice Address - Phone:918-322-3667
Practice Address - Fax:918-322-5923
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10425183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist