MEDICARE: EVERGREEN PHARMACY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	0201004585	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2146888	OTHER		PK

General Provider Information

NPI Number	:	1427465806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN PHARMACY, INC

Provider Business Mailing Address
First Line	:	7006 LITTLE RIVER TPKE STE B
Second Line	:
City	:	ANNANDALE
State	:	VA
Zip	:	22003-3218
Country	:	US
Telephone Number	:	703-992-8806
Fax Number	:	703-992-8805

Provider Business Practice Location Address
First Line	:	7006 LITTLE RIVER TPKE STE B
Second Line	:
City	:	ANNANDALE
State	:	VA
Zip	:	22003-3218
Country	:	US
Telephone Number	:	703-992-8806
Fax Number	:	703-992-8805

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JEE EUN KIM
Credential	:	PHARMD., RPH.
Telephone Number	:	703-825-1860

Provider Enumeration Date	:	07/17/2014
Last Update Date	:	12/10/2018

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Directions to “EVERGREEN PHARMACY, INC ” Practice Location

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