1427465806 NPI number — EVERGREEN PHARMACY, INC

Table of content: (NPI 1427465806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427465806 NPI number — EVERGREEN PHARMACY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN PHARMACY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ANNANDALE PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427465806
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7006 LITTLE RIVER TPKE STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANNANDALE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22003-3218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-992-8806
Provider Business Mailing Address Fax Number:
703-992-8805

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7006 LITTLE RIVER TPKE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANNANDALE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22003-3218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-992-8806
Provider Business Practice Location Address Fax Number:
703-992-8805
Provider Enumeration Date:
07/17/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KIM
Authorized Official First Name:
JEE EUN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
703-825-1860

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  0201004585 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2146888 . This is a "PK" identifier . This identifiers is of the category "OTHER".