Provider Demographics
NPI:1144558339
Name:EVERGREEN PHARMACY GROUP, INC.
Entity type:Organization
Organization Name:EVERGREEN PHARMACY GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JALAL
Authorized Official - Middle Name:HYDER
Authorized Official - Last Name:JAFRI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-940-0507
Mailing Address - Street 1:1037 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10566-2913
Mailing Address - Country:US
Mailing Address - Phone:914-734-8750
Mailing Address - Fax:914-734-8708
Practice Address - Street 1:1037 MAIN ST
Practice Address - Street 2:
Practice Address - City:PEEKSKILL
Practice Address - State:NY
Practice Address - Zip Code:10566-2913
Practice Address - Country:US
Practice Address - Phone:914-734-8750
Practice Address - Fax:914-734-8708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-27
Last Update Date:2009-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029859333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy