Provider Demographics
NPI:1821406711
Name:EVERGREEN RX PHARMACY INC
Entity type:Organization
Organization Name:EVERGREEN RX PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/PIC
Authorized Official - Prefix:MRS
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:T
Authorized Official - Last Name:TONGOC
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:951-878-9074
Mailing Address - Street 1:40963 WINCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-6031
Mailing Address - Country:US
Mailing Address - Phone:951-878-9074
Mailing Address - Fax:951-848-0788
Practice Address - Street 1:40963 WINCHESTER RD
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-6031
Practice Address - Country:US
Practice Address - Phone:951-878-9074
Practice Address - Fax:951-848-0788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7353110001Medicare NSC