Healthcare Provider Details

I. General information

NPI: 1245221068
Provider Name (Legal Business Name): GREEN TREE PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2005
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 CAROLYN DR
MINONK IL
61760
US

IV. Provider business mailing address

1305 N CAROLYN DR
MINONK IL
61760-9326
US

V. Phone/Fax

Practice location:
  • Phone: 309-432-3451
  • Fax: 309-432-2575
Mailing address:
  • Phone: 309-432-3451
  • Fax: 309-829-9512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number032-006965
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number058-013453
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number058-013453
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number058-013453
License Number StateIL

VIII. Authorized Official

Name: CHARLES T. GEORGE
Title or Position: VICE PRESIDENT
Credential: PHARMD
Phone: 309-432-3451