Provider Demographics
NPI:1023618527
Name:GREEN, JAMES MARK (DPH)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MARK
Last Name:GREEN
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 TINKER DIAGONAL
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-4622
Mailing Address - Country:US
Mailing Address - Phone:405-670-1030
Mailing Address - Fax:405-670-1036
Practice Address - Street 1:5401 TINKER DIAGONAL
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-4622
Practice Address - Country:US
Practice Address - Phone:405-670-1030
Practice Address - Fax:405-670-1036
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9958183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist