MEDICARE: EVANS DRUGS OF SAINT LOUIS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	5301006843	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0B90273	OTHER	MI	BLUE CROSS DME
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386644839
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVANS DRUGS OF SAINT LOUIS LLC

Provider Business Mailing Address
First Line	:	116 N MILL ST
Second Line	:
City	:	SAINT LOUIS
State	:	MI
Zip	:	48880-1521
Country	:	US
Telephone Number	:	989-681-6633
Fax Number	:	989-681-6644

Provider Business Practice Location Address
First Line	:	116 N MILL ST
Second Line	:
City	:	SAINT LOUIS
State	:	MI
Zip	:	48880-1521
Country	:	US
Telephone Number	:	989-681-6633
Fax Number	:	989-681-6644

Authorized Official
Title or Position	:	OWNER
Name	:	CHARLES WAYNE BROOKS
Credential	:	RPH
Telephone Number	:	989-463-3356

Provider Enumeration Date	:	07/27/2005
Last Update Date	:	08/22/2020

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