MEDICARE: EVERGREEN PHARMACEUTICAL OF CALIFORNIA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336L0003X	Long Term Care Pharmacy

General Provider Information

NPI Number	:	1013026608
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN PHARMACEUTICAL OF CALIFORNIA, LLC

Provider Business Mailing Address
First Line	:	1 CVS DR
Second Line	:	BOX 1075
City	:	WOONSOCKET
State	:	RI
Zip	:	02895-6146
Country	:	US
Telephone Number	:	401-765-1500
Fax Number	:

Provider Business Practice Location Address
First Line	:	879 2ND ST
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-4621
Country	:	US
Telephone Number	:	707-578-0399
Fax Number	:

Authorized Official
Title or Position	:	SR DIRECTOR, PAYER RELATIONS
Name	:	SUSAN COLBERT
Credential	:
Telephone Number	:	401-770-2751

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	01/04/2021

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