Provider Demographics
NPI:1851882104
Name:GREEN, BRANDON JASON
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:JASON
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 MILL POND LN APT 304
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-2112
Mailing Address - Country:US
Mailing Address - Phone:443-235-4311
Mailing Address - Fax:
Practice Address - Street 1:833 S SALISBURY BLVD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-6207
Practice Address - Country:US
Practice Address - Phone:443-235-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25499183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist