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General NPI Number Information
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NPI Number | 1750862983
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Entity Type | Organization
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Legal Business Name | GREEN LINE APOTHECARY OF PROVIDENCE LLC
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Dates
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Enumeration Date | 08/26/2018
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Last Update Date | 09/15/2023
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Provider Practice Location Address
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Address Line | 905 N MAIN ST
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City | PROVIDENCE
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State | RI
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Zip | 02904-5744
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Country | US
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Telephone | 401-633-8100
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Fax |
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Provider Business Mailing Address
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Address Line | 245 MAIN ST
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City | WAKEFIELD
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State | RI
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Zip | 02879-3527
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Country | US
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Telephone | 401-360-3200
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | CHRISTINA PROCACCIANTI
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Credential | PHARMD
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Telephone | 401-360-3200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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