Provider Demographics
NPI:1609181809
Name:GREEN, CHANDRA JORDAN
Entity Type:Individual
Prefix:MRS
First Name:CHANDRA
Middle Name:JORDAN
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11297 LAKE FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70128-2822
Mailing Address - Country:US
Mailing Address - Phone:504-248-2898
Mailing Address - Fax:504-248-2892
Practice Address - Street 1:11297 LAKE FOREST BLVD
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70128-2822
Practice Address - Country:US
Practice Address - Phone:504-248-2898
Practice Address - Fax:504-248-2892
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15286183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist