Provider Demographics
NPI:1114207057
Name:EVANGELISTA, MICHAEL M (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:M
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19201 BEAR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-2702
Mailing Address - Country:US
Mailing Address - Phone:760-961-6943
Mailing Address - Fax:
Practice Address - Street 1:19201 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-2702
Practice Address - Country:US
Practice Address - Phone:760-961-6943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57606183500000X
NV16838183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist