Provider Demographics
NPI:1770558371
Name:GREEN, LARRY WAYNE (RPH, CDE)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:WAYNE
Last Name:GREEN
Suffix:
Gender:M
Credentials:RPH, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3715 91ST AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98371-2214
Mailing Address - Country:US
Mailing Address - Phone:253-468-5566
Mailing Address - Fax:253-968-3349
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-2607
Practice Address - Fax:253-968-3349
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0132541835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist