Provider Demographics
NPI:1962011890
Name:GREEN STAR PHARMACY
Entity Type:Organization
Organization Name:GREEN STAR PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER/ PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:FRUSNEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AUGUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:123-924-0434
Mailing Address - Street 1:2611 30TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33976-4091
Mailing Address - Country:US
Mailing Address - Phone:239-240-4345
Mailing Address - Fax:239-931-3605
Practice Address - Street 1:2950 WINKLER AVE STE 701
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-9322
Practice Address - Country:US
Practice Address - Phone:239-931-3605
Practice Address - Fax:239-931-3605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1396015798Medicaid