Provider Demographics
NPI:1265714000
Name:GREEN, JUSTIN S (DPH)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:S
Last Name:GREEN
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 N 193RD EAST AVE
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-2862
Mailing Address - Country:US
Mailing Address - Phone:918-266-8837
Mailing Address - Fax:918-266-1512
Practice Address - Street 1:315 N 193RD EAST AVE
Practice Address - Street 2:
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-2862
Practice Address - Country:US
Practice Address - Phone:918-266-8837
Practice Address - Fax:918-266-1512
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist