Provider Demographics
NPI:1861852030
Name:EVERGREEN PHARMACY INC
Entity type:Organization
Organization Name:EVERGREEN PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT,PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DANG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:408-391-0700
Mailing Address - Street 1:EVERGREEN PHARMACY
Mailing Address - Street 2:PO BOX 731582
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95173-1582
Mailing Address - Country:US
Mailing Address - Phone:408-531-9961
Mailing Address - Fax:855-831-7973
Practice Address - Street 1:2365 QUIMBY RD STE 150
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95122-1337
Practice Address - Country:US
Practice Address - Phone:408-531-9961
Practice Address - Fax:855-831-7973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-02
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
CAPHY511983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158376OtherPK