Provider Demographics
NPI:1982976601
Name:GREEN, THOM L (RPH)
Entity Type:Individual
Prefix:
First Name:THOM
Middle Name:L
Last Name:GREEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:13501 PARK VISTA BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-3203
Mailing Address - Country:US
Mailing Address - Phone:817-837-8622
Mailing Address - Fax:866-423-2979
Practice Address - Street 1:13501 PARK VISTA BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-3203
Practice Address - Country:US
Practice Address - Phone:817-837-8622
Practice Address - Fax:866-423-2979
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX244731835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology