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General NPI Number Information
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NPI Number | 1245221068
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Entity Type | Organization
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Legal Business Name | GREEN TREE PHARMACY, INC.
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Dates
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Enumeration Date | 11/01/2005
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Last Update Date | 08/29/2024
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Provider Practice Location Address
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Address Line | 1305 CAROLYN DR
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City | MINONK
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State | IL
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Zip | 61760
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Country | US
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Telephone | 309-432-3451
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Fax | 309-432-2575
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Provider Business Mailing Address
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Address Line | 1305 N CAROLYN DR
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City | MINONK
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State | IL
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Zip | 61760-9326
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Country | US
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Telephone | 309-432-3451
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Fax | 309-829-9512
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | CHARLES T. GEORGE
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Credential | PHARMD
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Telephone | 309-432-3451
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 032-006965
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | 058-013453
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | 058-013453
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 058-013453
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License Number State | IL
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