Healthcare Provider Details

I. General information

NPI: 1740549500
Provider Name (Legal Business Name): EVERGREEN PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 E 10TH AVE
HIALEAH FL
33010-4645
US

IV. Provider business mailing address

875 E 10TH AVE
HIALEAH FL
33010-4645
US

V. Phone/Fax

Practice location:
  • Phone: 786-360-4945
  • Fax: 786-360-4955
Mailing address:
  • Phone: 786-360-4945
  • Fax: 786-360-4955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH26138
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: AUGUSTINE ORANUSI
Title or Position: OWNED/PHARMACIST
Credential:
Phone: 954-478-2950