MEDICARE: THOM L GREEN RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835X0200X	Oncology Pharmacist	24473	TX

General Provider Information

NPI Number	:	1982976601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOM L GREEN RPH

Provider Business Mailing Address
First Line	:	13501 PARK VISTA BLVD
Second Line	:	SUITE 150
City	:	FORT WORTH
State	:	TX
Zip	:	76177-3203
Country	:	US
Telephone Number	:	817-837-8622
Fax Number	:	866-423-2979

Provider Business Practice Location Address
First Line	:	13501 PARK VISTA BLVD
Second Line	:	SUITE 150
City	:	FORT WORTH
State	:	TX
Zip	:	76177-3203
Country	:	US
Telephone Number	:	817-837-8622
Fax Number	:	866-423-2979

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2012
Last Update Date	:	01/27/2012

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