Provider Demographics
NPI:1174662472
Name:SISSON, EVAN MACK (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:MACK
Last Name:SISSON
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 1:6006 HIDDEN ARBOR PL
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-7749
Mailing Address - Country:US
Mailing Address - Phone:804-748-3085
Mailing Address - Fax:
Practice Address - Street 1:410 N 12TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5062
Practice Address - Country:US
Practice Address - Phone:804-828-8076
Practice Address - Fax:804-828-8359
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02020107691835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy