Healthcare Provider Details

I. General information

NPI: 1407732449
Provider Name (Legal Business Name): EVERGREEN MEDICAL SUPPLY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2025
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 SCENIC HWY S STE 303
SNELLVILLE GA
30078-3115
US

IV. Provider business mailing address

2330 SCENIC HWY S STE 303
SNELLVILLE GA
30078-3115
US

V. Phone/Fax

Practice location:
  • Phone: 678-502-1440
  • Fax: 678-502-1441
Mailing address:
  • Phone: 678-502-1440
  • Fax: 678-502-1441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: LIJU THOMAS
Title or Position: CEO
Credential:
Phone: 267-368-9582