Healthcare Provider Details

I. General information

NPI: 1346241700
Provider Name (Legal Business Name): EVERGREEN RX INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11779 SANTA MONICA BLVD
LOS ANGELES CA
90025-2843
US

IV. Provider business mailing address

11779 SANTA MONICA BLVD
LOS ANGELES CA
90025-2843
US

V. Phone/Fax

Practice location:
  • Phone: 310-444-9011
  • Fax: 310-444-0418
Mailing address:
  • Phone: 310-444-9011
  • Fax: 310-444-0418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY51906
License Number StateCA

VIII. Authorized Official

Name: YURY AKOPYAN
Title or Position: OWNER
Credential:
Phone: 310-444-9011