Healthcare Provider Details

I. General information

NPI: 1588735146
Provider Name (Legal Business Name): CHARLES GOODWIN GREEN PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 S MIDLAND AVE
MONROE GA
30655-1629
US

IV. Provider business mailing address

PO BOX 1006
MONROE GA
30655-1006
US

V. Phone/Fax

Practice location:
  • Phone: 770-267-2539
  • Fax:
Mailing address:
  • Phone: 770-267-2539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH014218
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: