Provider Demographics
NPI:1750492617
Name:EVERGREEN PHARMACEUTICAL, LLC
Entity Type:Organization
Organization Name:EVERGREEN PHARMACEUTICAL, LLC
Other - Org Name:OMNICARE OF SPOKANE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR, PAYER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-2751
Mailing Address - Street 1:1 CVS DR
Mailing Address - Street 2:BOX 1075
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6146
Mailing Address - Country:US
Mailing Address - Phone:401-765-1500
Mailing Address - Fax:
Practice Address - Street 1:2820 N ASTOR ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-2112
Practice Address - Country:US
Practice Address - Phone:509-838-0870
Practice Address - Fax:509-455-5464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT230112Medicaid
ID0031815Medicaid
WA6023477Medicaid
WA9049867Medicaid
WA4927832OtherNCPDP
0541030010Medicare NSC