Provider Demographics
NPI:1386644839
Name:EVANS DRUGS OF SAINT LOUIS LLC
Entity Type:Organization
Organization Name:EVANS DRUGS OF SAINT LOUIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:989-463-3356
Mailing Address - Street 1:116 N MILL ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MI
Mailing Address - Zip Code:48880-1521
Mailing Address - Country:US
Mailing Address - Phone:989-681-6633
Mailing Address - Fax:989-681-6644
Practice Address - Street 1:116 N MILL ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MI
Practice Address - Zip Code:48880-1521
Practice Address - Country:US
Practice Address - Phone:989-681-6633
Practice Address - Fax:989-681-6644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301006843332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B90273OtherBLUE CROSS DME
MI3504815Medicaid
MI0B90273OtherBLUE CROSS DME