Healthcare Provider Details

I. General information

NPI: 1386270742
Provider Name (Legal Business Name): EAST ORANGE PHARMACY EVERGREEEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 EVERGREEN PL STE 104
EAST ORANGE NJ
07018-2114
US

IV. Provider business mailing address

60 EVERGREEN PL STE 104
EAST ORANGE NJ
07018-2114
US

V. Phone/Fax

Practice location:
  • Phone: 862-444-7188
  • Fax: 862-444-7183
Mailing address:
  • Phone: 862-444-7188
  • Fax: 862-444-7183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. TIM CHIU
Title or Position: PHARMACIST/OWNER
Credential:
Phone: 862-444-7188