Provider Demographics
NPI:1447722632
Name:EVERGREEN PHARMACY II, INC.
Entity type:Organization
Organization Name:EVERGREEN PHARMACY II, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KWANG-SIK
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:267-304-5831
Mailing Address - Street 1:702 DEKALB PIKE
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-1214
Mailing Address - Country:US
Mailing Address - Phone:610-616-0608
Mailing Address - Fax:610-616-0610
Practice Address - Street 1:702 DEKALB PIKE
Practice Address - Street 2:
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-1214
Practice Address - Country:US
Practice Address - Phone:610-616-0608
Practice Address - Fax:610-616-0610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy