Provider Demographics
NPI:1740263623
Name:FULL GREEN PHARMACY INC.
Entity type:Organization
Organization Name:FULL GREEN PHARMACY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JENSEN
Authorized Official - Middle Name:
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-494-1487
Mailing Address - Street 1:2340 E PACIFIC COAST HWY
Mailing Address - Street 2:STE G
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-1500
Mailing Address - Country:US
Mailing Address - Phone:562-494-1487
Mailing Address - Fax:562-986-4418
Practice Address - Street 1:2340 E PACIFIC COAST HWY
Practice Address - Street 2:STE G
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-1500
Practice Address - Country:US
Practice Address - Phone:562-494-1487
Practice Address - Fax:562-986-4418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY486303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9475033OtherBIN #
CAPHA486300Medicaid