Provider Demographics
NPI:1386270742
Name:EAST ORANGE PHARMACY EVERGREEEN LLC
Entity type:Organization
Organization Name:EAST ORANGE PHARMACY EVERGREEEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-444-7188
Mailing Address - Street 1:60 EVERGREEN PL STE 104
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-2114
Mailing Address - Country:US
Mailing Address - Phone:862-444-7188
Mailing Address - Fax:862-444-7183
Practice Address - Street 1:60 EVERGREEN PL STE 104
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2114
Practice Address - Country:US
Practice Address - Phone:862-444-7188
Practice Address - Fax:862-444-7183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RS00662900OtherBOARD OF PHARMACY