Provider Demographics
NPI:1972076792
Name:EVERGREEN PHARMACY & SUPPLIES LLC
Entity Type:Organization
Organization Name:EVERGREEN PHARMACY & SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:671-687-9175
Mailing Address - Street 1:520 ROUTE 8
Mailing Address - Street 2:
Mailing Address - City:MAITE
Mailing Address - State:GU
Mailing Address - Zip Code:96910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 ROUTE 8
Practice Address - Street 2:
Practice Address - City:MAITE
Practice Address - State:GU
Practice Address - Zip Code:96910
Practice Address - Country:US
Practice Address - Phone:671-477-5091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy