Provider Demographics
NPI:1346274693
Name:EVANS PHARMACY LLC
Entity Type:Organization
Organization Name:EVANS PHARMACY LLC
Other - Org Name:EVANS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NUNLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-234-4343
Mailing Address - Street 1:1106 W WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-2503
Mailing Address - Country:US
Mailing Address - Phone:580-234-4343
Mailing Address - Fax:580-234-5477
Practice Address - Street 1:1106 W WILLOW RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-2503
Practice Address - Country:US
Practice Address - Phone:580-234-4343
Practice Address - Fax:580-234-5477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5-5107332B00000X, 332BP3500X, 333600000X, 3336C0003X, 3336L0003X, 3336L0003X, 3336M0002X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100247450AMedicaid
OK100232660EMedicaid
OK100247450CMedicaid
OK=========001OtherBCBS HIT
OK100247450CMedicaid
OK100232660EMedicaid
OK100247450CMedicaid
OK700522168Medicare ID - Type UnspecifiedPART B