Provider Demographics
NPI:1174047153
Name:GREEN, MAKENZIE ELISABETH
Entity type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:ELISABETH
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 E CENTENNIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-5633
Mailing Address - Country:US
Mailing Address - Phone:702-399-3405
Mailing Address - Fax:
Practice Address - Street 1:565 E CENTENNIAL PKWY
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081-5633
Practice Address - Country:US
Practice Address - Phone:702-399-3405
Practice Address - Fax:702-399-9602
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0010216183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist