Healthcare Provider Details

I. General information

NPI: 1942306527
Provider Name (Legal Business Name): SUZANNE KAY GREEN R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 S MAIN ST
DE FOREST WI
53532-1421
US

IV. Provider business mailing address

57 KNUTSON DR
MADISON WI
53704
US

V. Phone/Fax

Practice location:
  • Phone: 608-846-4736
  • Fax:
Mailing address:
  • Phone: 608-241-7745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12701
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: