Provider Demographics
NPI:1154746998
Name:EVERGREEN RX INC
Entity type:Organization
Organization Name:EVERGREEN RX INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAREK
Authorized Official - Middle Name:
Authorized Official - Last Name:JAWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-674-9800
Mailing Address - Street 1:20010 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-3250
Mailing Address - Country:US
Mailing Address - Phone:313-336-3500
Mailing Address - Fax:313-336-3565
Practice Address - Street 1:20010 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-3250
Practice Address - Country:US
Practice Address - Phone:313-336-3500
Practice Address - Fax:313-336-3565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-04
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010073513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144664OtherPK