Provider Demographics
NPI:1720191828
Name:GREEN, CHARLES ROWAND (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROWAND
Last Name:GREEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 N EL DORADO ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5930
Mailing Address - Country:US
Mailing Address - Phone:209-466-2381
Mailing Address - Fax:209-465-1398
Practice Address - Street 1:1610 N EL DORADO ST
Practice Address - Street 2:SUITE #1
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5930
Practice Address - Country:US
Practice Address - Phone:209-466-2381
Practice Address - Fax:209-465-1398
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25546183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist