=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700165289
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVAN RANDALL CALLIN PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2011
-----------------------------------------------------
Last Update Date | 08/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 CLINTON AVE S
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14620-1448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-279-4790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 48 WINCANTON DR
-----------------------------------------------------
City | FAIRPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14450-3847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-750-5751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 055831
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------