Provider Demographics
NPI:1164918488
Name:EVANGELISTI, STEPHANIE LEE (PHARMD, MS)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:LEE
Last Name:EVANGELISTI
Suffix:
Gender:F
Credentials:PHARMD, MS
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LEE
Other - Last Name:SOUTHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2596 F RD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-1443
Mailing Address - Country:US
Mailing Address - Phone:970-644-3227
Mailing Address - Fax:970-644-3963
Practice Address - Street 1:2596 F RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1443
Practice Address - Country:US
Practice Address - Phone:970-644-3227
Practice Address - Fax:970-644-3963
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202214193183500000X
COPHA.0021144183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist