Provider Demographics
NPI:1245932649
Name:GREEN, KRISTA JEANNETTE
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:JEANNETTE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 ROSEVILLE SQ
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-2808
Mailing Address - Country:US
Mailing Address - Phone:916-784-1590
Mailing Address - Fax:916-784-1728
Practice Address - Street 1:446 ROSEVILLE SQ
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-2808
Practice Address - Country:US
Practice Address - Phone:916-784-1590
Practice Address - Fax:916-784-1728
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33981183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist