Provider Demographics
NPI:1447368832
Name:EVANS, ERIC PAUL
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:PAUL
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18793 VISTA OAK DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:TX
Mailing Address - Zip Code:75762-8736
Mailing Address - Country:US
Mailing Address - Phone:903-581-0106
Mailing Address - Fax:
Practice Address - Street 1:308 W LARISSA ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-2319
Practice Address - Country:US
Practice Address - Phone:903-586-9804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36954183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist