=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598357030
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN L GREEN DPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2021
-----------------------------------------------------
Last Update Date | 02/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 262 E 141ST ST
-----------------------------------------------------
City | GLENPOOL
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74033-3569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-322-3667
-----------------------------------------------------
Fax | 918-322-5923
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 887
-----------------------------------------------------
City | GLENPOOL
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74033-0887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-322-3667
-----------------------------------------------------
Fax | 918-322-5923
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 10425
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------