Provider Demographics
NPI:1245221068
Name:GREEN TREE PHARMACY, INC.
Entity type:Organization
Organization Name:GREEN TREE PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:T
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:309-432-3451
Mailing Address - Street 1:1305 N CAROLYN DR
Mailing Address - Street 2:
Mailing Address - City:MINONK
Mailing Address - State:IL
Mailing Address - Zip Code:61760-9326
Mailing Address - Country:US
Mailing Address - Phone:309-432-3451
Mailing Address - Fax:309-829-9512
Practice Address - Street 1:1305 CAROLYN DR
Practice Address - Street 2:
Practice Address - City:MINONK
Practice Address - State:IL
Practice Address - Zip Code:61760
Practice Address - Country:US
Practice Address - Phone:309-432-3451
Practice Address - Fax:309-432-2575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL032-006965333600000X
IL058-0134533336L0003X, 3336S0011X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid