Provider Demographics
NPI:1902180995
Name:GREEN, ELIZABETH (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-1160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1133 N JOHNS ST
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-1277
Practice Address - Country:US
Practice Address - Phone:608-935-2041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15979-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist