Provider Demographics
NPI:1760564439
Name:GREEN, TALMADGE R (PD)
Entity Type:Individual
Prefix:MR
First Name:TALMADGE
Middle Name:R
Last Name:GREEN
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-6931
Mailing Address - Country:US
Mailing Address - Phone:318-442-4485
Mailing Address - Fax:318-443-6410
Practice Address - Street 1:1414 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-6931
Practice Address - Country:US
Practice Address - Phone:318-442-4485
Practice Address - Fax:318-443-6410
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11049183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1234869Medicaid
LA914-IROtherLA PHARMACY PERMIT NO.
1903360OtherNABP
LA1234869Medicaid
LA914-IROtherLA PHARMACY PERMIT NO.