Healthcare Provider Details

I. General information

NPI: 1982517116
Provider Name (Legal Business Name): EVAN GRIESSE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HIGHWAY 491 N
SHIPROCK NM
87420
US

IV. Provider business mailing address

US HIGHWAY 491 N
SHIPROCK NM
87420
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6001
  • Fax:
Mailing address:
  • Phone: 505-368-6001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberPD17808
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: