Healthcare Provider Details

I. General information

NPI: 1477473924
Provider Name (Legal Business Name): DAVID GREEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 SAINT FRANCIS AVE
SHAKOPEE MN
55379-3374
US

IV. Provider business mailing address

1455 SAINT FRANCIS AVE
SHAKOPEE MN
55379-3374
US

V. Phone/Fax

Practice location:
  • Phone: 952-428-2020
  • Fax:
Mailing address:
  • Phone: 952-428-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number122808
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: