Provider Demographics
NPI:1396933545
Name:EVERGREEN PHARMACY INC
Entity type:Organization
Organization Name:EVERGREEN PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DANG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:408-270-0670
Mailing Address - Street 1:PO BOX 731556
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95173-1556
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2690 S WHITE RD
Practice Address - Street 2:STE 200A
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-2076
Practice Address - Country:US
Practice Address - Phone:408-270-0670
Practice Address - Fax:855-274-7399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA488263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1396933545Medicaid
2112962OtherPK
2112962OtherPK