Healthcare Provider Details

I. General information

NPI: 1770558371
Provider Name (Legal Business Name): LARRY WAYNE GREEN RPH, CDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

3715 91ST AVENUE CT E
EDGEWOOD WA
98371-2214
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2607
  • Fax: 253-968-3349
Mailing address:
  • Phone: 253-468-5566
  • Fax: 253-968-3349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number013254
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: