Provider Demographics
NPI:1710310529
Name:GREEN, CHARLIE JAMES (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:CHARLIE
Middle Name:JAMES
Last Name:GREEN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-2970
Mailing Address - Country:US
Mailing Address - Phone:207-432-2857
Mailing Address - Fax:
Practice Address - Street 1:19 PORTLAND RD
Practice Address - Street 2:
Practice Address - City:BRIDGTON
Practice Address - State:ME
Practice Address - Zip Code:04009-1229
Practice Address - Country:US
Practice Address - Phone:207-647-3445
Practice Address - Fax:207-647-2086
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR12947183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist