Provider Demographics
NPI:1457459331
Name:EVASON PHARMACIES INC
Entity Type:Organization
Organization Name:EVASON PHARMACIES INC
Other - Org Name:SAM'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:910-285-2937
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:ROSE HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28458-1086
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 S SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:ROSE HILL
Practice Address - State:NC
Practice Address - Zip Code:28458
Practice Address - Country:US
Practice Address - Phone:910-289-4271
Practice Address - Fax:910-289-3880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC075443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0315432Medicaid
3431690OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC0315432Medicaid