Provider Demographics
NPI:1114490729
Name:EVANS, CARL WILLIAM (RPH)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:WILLIAM
Last Name:EVANS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3061 BOCASTLE CT
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-5074
Mailing Address - Country:US
Mailing Address - Phone:614-404-0937
Mailing Address - Fax:
Practice Address - Street 1:3061 BOCASTLE CT
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-5074
Practice Address - Country:US
Practice Address - Phone:614-404-0937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03212560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03212560OtherRPH LICENSE