Provider Demographics
NPI:1437271392
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:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:WHITEHEAD
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:2007-04-04
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5-5107332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100232660EMedicaid
OK5467140001Medicare NSC