Provider Demographics
NPI:1760718779
Name:GREEN, THOMAS M (REG PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:M
Last Name:GREEN
Suffix:
Gender:M
Credentials:REG PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:TYBEE ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31328-8752
Mailing Address - Country:US
Mailing Address - Phone:912-786-7878
Mailing Address - Fax:
Practice Address - Street 1:303 1ST AVE
Practice Address - Street 2:
Practice Address - City:TYBEE ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31328-8752
Practice Address - Country:US
Practice Address - Phone:912-786-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH018645183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist