MEDICARE: EVERGREEN CORPORATION

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	333600000X	Pharmacy	CF58547	WA

General Provider Information

NPI Number	:	1962477737
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN CORPORATION

Provider Business Mailing Address
First Line	:	134 CENTRAL WAY
Second Line	:
City	:	KIRKLAND
State	:	WA
Zip	:	98033-6106
Country	:	US
Telephone Number	:	425-803-6800
Fax Number	:	425-803-6811

Provider Business Practice Location Address
First Line	:	134 CENTRAL WAY
Second Line	:
City	:	KIRKLAND
State	:	WA
Zip	:	98033-6106
Country	:	US
Telephone Number	:	425-803-6800
Fax Number	:	425-803-6811

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. OLEG ORDINARTSEV
Credential	:
Telephone Number	:	425-803-6800

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	08/22/2020

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Directions to “EVERGREEN CORPORATION ” Practice Location

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