1396933545 NPI number — EVERGREEN PHARMACY INC

Table of content: (NPI 1396933545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396933545 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:
Provider Other Organization Name Type Code:
6
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:
1396933545
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 731556
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95173-1556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2690 S WHITE RD
Provider Second Line Business Practice Location Address:
STE 200A
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95148-2076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-270-0670
Provider Business Practice Location Address Fax Number:
855-274-7399
Provider Enumeration Date:
10/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DANG
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
408-270-0670

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  48826 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1396933545 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2112962 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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