Organization
EVERGREEN SHOP PHARMACY INC
Active
Other names
Evergreen Shop Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
MANAL KEST (CORPARATION OFFICER)
(310) 866-3415
Entity
Organization
Contact information
Practice address
150 S GRAND AVE STE K, GLENDORA, CA 91741-4715
(626) 335-2442
(626) 335-0220
Mailing address
150 S GRAND AVE STE K, GLENDORA, CA 91741-4715
(626) 335-2442
(626) 335-0220
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
54456
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2162500
PK
—
Enumeration date
07/14/2016
Last updated
08/10/2016
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