Provider Demographics
NPI:1336261486
Name:GREEN, TANGIE D (RPH)
Entity Type:Individual
Prefix:
First Name:TANGIE
Middle Name:D
Last Name:GREEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 WEST 6TH STREET
Mailing Address - Street 2:MC-47
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206
Mailing Address - Country:US
Mailing Address - Phone:904-665-1772
Mailing Address - Fax:
Practice Address - Street 1:515 WEST 6TH STREET
Practice Address - Street 2:MC-47
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206
Practice Address - Country:US
Practice Address - Phone:904-665-1772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS31558183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist