Provider Demographics
NPI:1740549500
Name:EVERGREEN PHARMACY INC
Entity type:Organization
Organization Name:EVERGREEN PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNED/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ORANUSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-478-2950
Mailing Address - Street 1:875 E 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-4645
Mailing Address - Country:US
Mailing Address - Phone:786-360-4945
Mailing Address - Fax:786-360-4955
Practice Address - Street 1:875 E 10TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-4645
Practice Address - Country:US
Practice Address - Phone:786-360-4945
Practice Address - Fax:786-360-4955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-14
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
FLPH261383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008565300Medicaid
2137257OtherPK