Provider Demographics
NPI:1881708865
Name:GREEN TREE PHARMACIES LLC
Entity type:Organization
Organization Name:GREEN TREE PHARMACIES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-265-2191
Mailing Address - Street 1:21430 LA HWY 20
Mailing Address - Street 2:
Mailing Address - City:VACHERIE
Mailing Address - State:LA
Mailing Address - Zip Code:70090
Mailing Address - Country:US
Mailing Address - Phone:225-265-2191
Mailing Address - Fax:225-265-8007
Practice Address - Street 1:21430 LA HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:VACHERIE
Practice Address - State:LA
Practice Address - Zip Code:70090
Practice Address - Country:US
Practice Address - Phone:225-265-2191
Practice Address - Fax:225-265-8007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY.006783-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143830OtherPK
LA2202481Medicaid