Provider Demographics
NPI:1730908971
Name:GREEN, TIMOTHY EDGAR (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:EDGAR
Last Name:GREEN
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16806 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-2662
Mailing Address - Country:US
Mailing Address - Phone:602-794-3602
Mailing Address - Fax:602-794-3612
Practice Address - Street 1:16806 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-2662
Practice Address - Country:US
Practice Address - Phone:602-794-3602
Practice Address - Fax:602-794-3612
Is Sole Proprietor?:No
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS027273183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist