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General NPI Number Information
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NPI Number | 1760523625
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Entity Type | Organization
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Legal Business Name | MIRANDA GREEN
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Dates
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Enumeration Date | 02/12/2007
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Last Update Date | 11/18/2015
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Provider Practice Location Address
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Address Line | 101 W AVENUE D
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City | HEAVENER
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State | OK
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Zip | 74937-3017
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Country | US
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Telephone | 918-653-4803
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Fax | 918-653-3520
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Provider Business Mailing Address
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Address Line | 101 W AVENUE D
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City | HEAVENER
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State | OK
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Zip | 74937-3017
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Country | US
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Telephone | 918-653-4803
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Fax | 918-653-3520
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Authorized Official
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Title or Position | OWNER
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Name | MIRANDA GREEN
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Credential | PD
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Telephone | 918-653-4803
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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 | 19-5501
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License Number State | OK
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