Provider Demographics
NPI:1427465806
Name:EVERGREEN PHARMACY, INC
Entity type:Organization
Organization Name:EVERGREEN PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEE EUN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:703-825-1860
Mailing Address - Street 1:7006 LITTLE RIVER TPKE STE B
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-3218
Mailing Address - Country:US
Mailing Address - Phone:703-992-8806
Mailing Address - Fax:703-992-8805
Practice Address - Street 1:7006 LITTLE RIVER TPKE STE B
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3218
Practice Address - Country:US
Practice Address - Phone:703-992-8806
Practice Address - Fax:703-992-8805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010045853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146888OtherPK