Healthcare Provider Details

I. General information

NPI: 1144558339
Provider Name (Legal Business Name): EVERGREEN PHARMACY GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2009
Last Update Date: 11/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 MAIN ST
PEEKSKILL NY
10566-2913
US

IV. Provider business mailing address

1037 MAIN ST
PEEKSKILL NY
10566-2913
US

V. Phone/Fax

Practice location:
  • Phone: 914-734-8750
  • Fax: 914-734-8708
Mailing address:
  • Phone: 914-734-8750
  • Fax: 914-734-8708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number029859
License Number StateNY

VIII. Authorized Official

Name: MR. JALAL HYDER JAFRI
Title or Position: PRESIDENT
Credential:
Phone: 203-940-0507