Provider Demographics
NPI:1750862983
Name:GREEN LINE APOTHECARY OF PROVIDENCE LLC
Entity Type:Organization
Organization Name:GREEN LINE APOTHECARY OF PROVIDENCE LLC
Other - Org Name:GREEN LINE APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PROCACCIANTI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:401-360-3200
Mailing Address - Street 1:245 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-3527
Mailing Address - Country:US
Mailing Address - Phone:401-360-3200
Mailing Address - Fax:
Practice Address - Street 1:905 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5744
Practice Address - Country:US
Practice Address - Phone:401-633-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-26
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy