Healthcare Provider Details

I. General information

NPI: 1023855335
Provider Name (Legal Business Name): SHELLY ROSE EVIA PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 CAMPBELL AVE
WEST HAVEN CT
06516-2770
US

IV. Provider business mailing address

65 ALYCE TER
WATERBURY CT
06708-1566
US

V. Phone/Fax

Practice location:
  • Phone: 203-932-5711
  • Fax:
Mailing address:
  • Phone: 203-808-0831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPCT.0016705
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: