Provider Demographics
NPI:1457453870
Name:EVANS DRUGS OF TEKONSHA LLC
Entity Type:Organization
Organization Name:EVANS DRUGS OF TEKONSHA LLC
Other - Org Name:EVANS DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GABE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAWAIDEH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:248-931-5398
Mailing Address - Street 1:129 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TEKONSHA
Mailing Address - State:MI
Mailing Address - Zip Code:49092-5114
Mailing Address - Country:US
Mailing Address - Phone:517-767-3474
Mailing Address - Fax:517-767-4603
Practice Address - Street 1:129 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TEKONSHA
Practice Address - State:MI
Practice Address - Zip Code:49092-5114
Practice Address - Country:US
Practice Address - Phone:517-767-3474
Practice Address - Fax:517-767-4603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010085073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2339388OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MI1696265Medicaid
0284050001Medicare NSC