Provider Demographics
NPI:1407461890
Name:EVANGELISTA CORDON, MARY ANTONETTE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANTONETTE
Last Name:EVANGELISTA CORDON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:ANTONETTE
Other - Last Name:CORDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:380 MATHER ST APT 6414
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-3199
Mailing Address - Country:US
Mailing Address - Phone:201-365-8136
Mailing Address - Fax:
Practice Address - Street 1:267 GRANT ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2870
Practice Address - Country:US
Practice Address - Phone:203-384-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202217006183500000X
CTPTP.0000548183500000X
NJ28RI03890300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPTP.0000548OtherCONNECTICUT BOARD OF PHARMACY
VA0202217006OtherVIRGINIA BOARD OF PHARMACY
NJ28RI03890300OtherNEW JERSEY BOARD OF PHARMACY