Healthcare Provider Details

I. General information

NPI: 1164331963
Provider Name (Legal Business Name): FELICIA GREEN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2026
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HOSPITAL WAY
POCATELLO ID
83201-5175
US

IV. Provider business mailing address

529 W BONNEVILLE ST APT 2
POCATELLO ID
83204-3341
US

V. Phone/Fax

Practice location:
  • Phone: 208-239-1382
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP10762
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: