Provider Demographics
NPI:1619257615
Name:GREEN, MELISSA D (PHARMD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:D
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 S APPLE ST
Mailing Address - Street 2:A206
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5178
Mailing Address - Country:US
Mailing Address - Phone:801-362-5628
Mailing Address - Fax:
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:BLDG 44
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6563183500000X
UT6037157-1702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist