Healthcare Provider Details

I. General information

NPI: 1043868920
Provider Name (Legal Business Name): MICHAEL EVANS RPX
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 COLUMBIA TPKE
CASTLETON NY
12033-9535
US

IV. Provider business mailing address

8 BELLWOOD LN
CASTLETON NY
12033-9558
US

V. Phone/Fax

Practice location:
  • Phone: 518-477-8166
  • Fax:
Mailing address:
  • Phone: 518-479-7664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number065893
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: