Healthcare Provider Details

I. General information

NPI: 1720753965
Provider Name (Legal Business Name): RYAN GREEN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7480 LEE HWY
FAIRLAWN VA
24141-8591
US

IV. Provider business mailing address

7480 LEE HWY
FAIRLAWN VA
24141-8591
US

V. Phone/Fax

Practice location:
  • Phone: 540-633-6710
  • Fax:
Mailing address:
  • Phone: 540-633-6710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number0202219634
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: