Provider Demographics
NPI:1760523625
Name:MIRANDA GREEN
Entity Type:Organization
Organization Name:MIRANDA GREEN
Other - Org Name:GREENS PRESCRIPTION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:918-653-4803
Mailing Address - Street 1:101 W AVENUE D
Mailing Address - Street 2:
Mailing Address - City:HEAVENER
Mailing Address - State:OK
Mailing Address - Zip Code:74937-3017
Mailing Address - Country:US
Mailing Address - Phone:918-653-4803
Mailing Address - Fax:918-653-3520
Practice Address - Street 1:101 W AVENUE D
Practice Address - Street 2:
Practice Address - City:HEAVENER
Practice Address - State:OK
Practice Address - Zip Code:74937-3017
Practice Address - Country:US
Practice Address - Phone:918-653-4803
Practice Address - Fax:918-653-3520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK19-55013336C0003X
OK1955013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100234100Medicaid
2072800OtherPK