NPIMap

Organization Active NPI

Evergreen Pharmacy Inc

  • Community/Retail Pharmacy
  • San Jose, CA
National Provider Identifier
1396933545
Registry record updated Feb 28, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
48826 Issued in CA
Legal business name
EVERGREEN PHARMACY INC
Practice address
2690 S White Rd
Ste 200a
San Jose, CA 95148-2076
Phone
(408) 270-0670
Fax
(855) 274-7399
NPI assigned
Oct 11, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 28, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kevin Dang, PHARM.DNPI 1063861466
Title
President
Phone
(408) 270-0670

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X 48826 CA Primary

Addresses

Primary practice location

2690 S White Rd
Ste 200a
San Jose, CA 95148-2076

Mailing address

PO Box 731556
San Jose, CA 95173-1556

Other identifiers 2

IdentifierTypeStateIssuer
1396933545MedicaidCA
2112962OtherPK

Other names 1

  • EVERGREEN PHARMACY Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100930029555 CA DME Supplier - Pharmacy 0143426536 Practice locations: San Jose, CA

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Evergreen Pharmacy2690 S White Rd, San Jose, CA 95148-2076(408) 270-0670 Epoetin|Immunosuppressive Drugs|Infusion Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Blood Glucose Monitors/Supplies (Non-Mail Order)|Heat & Cold Applications|Insulin Infusion Pumps and/or Supplies|Canes and/or Crutches|Walkers|Wheelchairs (Standard Manual)|Wheelchairs (Standa… Accepts assignmentParticipating since Jan 1, 2008

National Provider Directory

National Provider Directory
Tax ID family
Evergreen Pharmacy2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1192060800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1488240000000",
    "number": "1396933545",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 731556",
            "city": "SAN JOSE",
            "state": "CA",
            "postal_code": "951731556"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2690 S WHITE RD",
            "address_2": "STE 200A",
            "city": "SAN JOSE",
            "state": "CA",
            "postal_code": "951482076",
            "telephone_number": "408-270-0670",
            "fax_number": "855-274-7399"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN PHARMACY INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-10-11",
        "last_updated": "2017-02-28",
        "status": "A",
        "authorized_official_last_name": "DANG",
        "authorized_official_first_name": "KEVIN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "408-270-0670",
        "authorized_official_credential": "PHARM.D"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "CA",
            "license": "48826",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1396933545",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2112962",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "EVERGREEN PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in San Jose, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 28, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.