Provider Demographics
NPI:1588054332
Name:EVERGREENHEALTHCARE
Entity type:Organization
Organization Name:EVERGREENHEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CERMAK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:425-899-2783
Mailing Address - Street 1:12333 NE 130TH LN
Mailing Address - Street 2:TAN 415
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-7467
Mailing Address - Country:US
Mailing Address - Phone:425-899-2783
Mailing Address - Fax:425-899-2784
Practice Address - Street 1:12333 NE 130TH LN
Practice Address - Street 2:TAN 415
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7467
Practice Address - Country:US
Practice Address - Phone:425-899-2783
Practice Address - Fax:425-899-2784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH0009804261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH00009804OtherPHARMACY LICENSE