Healthcare Provider Details

I. General information

NPI: 1487101754
Provider Name (Legal Business Name): EVERGREEN PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2016
Last Update Date: 03/07/2023
Certification Date: 05/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 W GREENFIELD AVE
WEST ALLIS WI
53214-3953
US

IV. Provider business mailing address

10101 W GREENFIELD AVE
WEST ALLIS WI
53214-3953
US

V. Phone/Fax

Practice location:
  • Phone: 414-533-6600
  • Fax: 414-533-6601
Mailing address:
  • Phone: 414-533-6600
  • Fax: 414-533-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number9421-42
License Number StateWI

VIII. Authorized Official

Name: RICHARD A PEARSON
Title or Position: CEO
Credential:
Phone: 414-727-5750