Provider Demographics
NPI:1417767765
Name:EVERGREEN HEALTH RX LLC
Entity type:Organization
Organization Name:EVERGREEN HEALTH RX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-344-0394
Mailing Address - Street 1:165 FERRY ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-2179
Mailing Address - Country:US
Mailing Address - Phone:973-344-0394
Mailing Address - Fax:
Practice Address - Street 1:165 FERRY ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-2179
Practice Address - Country:US
Practice Address - Phone:973-344-0394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy