Provider Demographics
NPI:1871625459
Name:EOVALDI, MARY (RPH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:EOVALDI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50290 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48051-4003
Mailing Address - Country:US
Mailing Address - Phone:586-949-6110
Mailing Address - Fax:586-949-6212
Practice Address - Street 1:50290 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48051-4003
Practice Address - Country:US
Practice Address - Phone:586-949-6110
Practice Address - Fax:586-949-6212
Is Sole Proprietor?:No
Enumeration Date:2007-03-10
Last Update Date:2013-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI423955OtherNABP