Provider Demographics
NPI:1174772842
Name:GREEN, ANSU
Entity type:Individual
Prefix:
First Name:ANSU
Middle Name:
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 1:5038 HILLTOP ACRES RD
Mailing Address - Street 2:
Mailing Address - City:PERRY HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21128-9629
Mailing Address - Country:US
Mailing Address - Phone:410-931-0877
Mailing Address - Fax:
Practice Address - Street 1:29 SHIPPING PL
Practice Address - Street 2:
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-4318
Practice Address - Country:US
Practice Address - Phone:410-282-0020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18278183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist