Provider Demographics
NPI:1043868920
Name:EVANS, MICHAEL (RPX)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:RPX
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 BELLWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-9558
Mailing Address - Country:US
Mailing Address - Phone:518-479-7664
Mailing Address - Fax:
Practice Address - Street 1:1645 COLUMBIA TPKE
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9535
Practice Address - Country:US
Practice Address - Phone:518-477-8166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065893183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist