Provider Demographics
NPI:1083067995
Name:EVERGREEN SHOP PHARMACY INC
Entity Type:Organization
Organization Name:EVERGREEN SHOP PHARMACY INC
Other - Org Name:EVERGREEN SHOP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPARATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MANAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-866-3415
Mailing Address - Street 1:150 S GRAND AVE STE K
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4715
Mailing Address - Country:US
Mailing Address - Phone:626-335-2442
Mailing Address - Fax:626-335-0220
Practice Address - Street 1:150 S GRAND AVE STE K
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4715
Practice Address - Country:US
Practice Address - Phone:626-335-2442
Practice Address - Fax:626-335-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-14
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA544563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2162500OtherPK