Provider Demographics
NPI:1275181851
Name:EVANS, MARY LEANN (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEANN
Last Name:EVANS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 STEVENS XING
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9099
Mailing Address - Country:US
Mailing Address - Phone:706-736-2418
Mailing Address - Fax:
Practice Address - Street 1:950 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2608
Practice Address - Country:US
Practice Address - Phone:706-733-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017759183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist