Provider Demographics
NPI:1639548944
Name:GREEN, JAMES EARL
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EARL
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JIM
Other - Middle Name:EARL
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:1401 OLD EXETER RD
Mailing Address - Street 2:WALMART PHARMACY #0914
Mailing Address - City:CASSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65625-9430
Mailing Address - Country:US
Mailing Address - Phone:417-847-3180
Mailing Address - Fax:417-847-3650
Practice Address - Street 1:1401 OLD EXETER RD
Practice Address - Street 2:WALMART PHARMACY #0914
Practice Address - City:CASSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65625-9430
Practice Address - Country:US
Practice Address - Phone:417-847-3180
Practice Address - Fax:417-847-3650
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO040660183500000X
NE8917183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist