Provider Demographics
NPI:1487101754
Name:EVERGREEN PHARMACY LLC
Entity type:Organization
Organization Name:EVERGREEN PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-727-5750
Mailing Address - Street 1:10101 W GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3953
Mailing Address - Country:US
Mailing Address - Phone:414-533-6600
Mailing Address - Fax:414-533-6601
Practice Address - Street 1:10101 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-3953
Practice Address - Country:US
Practice Address - Phone:414-533-6600
Practice Address - Fax:414-533-6601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 3336S0011X
WI9421-42333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9421-42OtherSTATE PHARMACY LICENSE
WI9421-42OtherSTATE PHARMACY LICENSE