MEDICARE: EVERGREEN PHARMACY INC

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	333600000X	Pharmacy

General Provider Information

NPI Number	:	1033740691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN PHARMACY INC

Provider Business Mailing Address
First Line	:	4110 S MARYLAND PKWY STE 17
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-7505
Country	:	US
Telephone Number	:	702-462-6262
Fax Number	:	702-462-5654

Provider Business Practice Location Address
First Line	:	4110 S MARYLAND PKWY STE 17
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-7505
Country	:	US
Telephone Number	:	702-462-6262
Fax Number	:	702-462-5654

Authorized Official
Title or Position	:	DIRECTOR
Name	:	SHEREEN HASSAN
Credential	:
Telephone Number	:	480-519-4640

Provider Enumeration Date	:	01/31/2020
Last Update Date	:	01/31/2020

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Directions to “EVERGREEN PHARMACY INC ” Practice Location

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