Provider Demographics
NPI:1346461829
Name:EVANS, CHARLES WESLEY (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WESLEY
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 1:2303 SW PETTIS SPRINGS CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32331
Mailing Address - Country:US
Mailing Address - Phone:850-948-9921
Mailing Address - Fax:850-973-2987
Practice Address - Street 1:1219 W BASE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340
Practice Address - Country:US
Practice Address - Phone:850-973-2719
Practice Address - Fax:850-973-2987
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0019394183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist