Provider Demographics
NPI:1881720050
Name:EVERGREEN PHARMACY, P.C.
Entity type:Organization
Organization Name:EVERGREEN PHARMACY, P.C.
Other - Org Name:<UNAVAIL>
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:215-393-0902
Mailing Address - Street 1:1222 WELSH RD
Mailing Address - Street 2:SUITE# C-1
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-2054
Mailing Address - Country:US
Mailing Address - Phone:215-393-0902
Mailing Address - Fax:215-393-0904
Practice Address - Street 1:1222 WELSH RD
Practice Address - Street 2:SUITE# C-1
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-2054
Practice Address - Country:US
Practice Address - Phone:215-393-0902
Practice Address - Fax:215-393-0904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-24
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4814923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014115870001Medicaid
PA1014115870001Medicaid