Provider Demographics
NPI:1730883968
Name:GREEN, MATTHEW (PHARMD, RPH)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:863 CODY DR
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:KY
Mailing Address - Zip Code:41143-8627
Mailing Address - Country:US
Mailing Address - Phone:606-922-5182
Mailing Address - Fax:
Practice Address - Street 1:410 W TOM T HALL BLVD
Practice Address - Street 2:
Practice Address - City:OLIVE HILL
Practice Address - State:KY
Practice Address - Zip Code:41164-5655
Practice Address - Country:US
Practice Address - Phone:606-922-5182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY023365183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist