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General NPI Number Information
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NPI Number | 1275632036
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Entity Type | Organization
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Legal Business Name | GREEN CLINIC LLC
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 09/19/2025
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Provider Practice Location Address
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Address Line | 1200 S FARMERVILLE ST
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City | RUSTON
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State | LA
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Zip | 71270-5941
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Country | US
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Telephone | 318-251-6337
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Fax | 318-251-6334
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Provider Business Mailing Address
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Address Line | 1200 SOUTH FARMERVILLE STREET
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City | RUSTON
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State | LA
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Zip | 71270
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Country | US
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Telephone | 318-251-6337
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Fax | 318-251-6334
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Authorized Official
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Title or Position | PHARMACY DIRECTOR
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Name | MARY CROWE
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Credential | RPH
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Telephone | 318-251-6337
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHY.005703-IR
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License Number State | LA
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