Provider Demographics
NPI:1467050609
Name:STOUDT, EVAN MATTHEW
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:MATTHEW
Last Name:STOUDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-3015
Mailing Address - Country:US
Mailing Address - Phone:609-206-9435
Mailing Address - Fax:
Practice Address - Street 1:5537 MARKET ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3209
Practice Address - Country:US
Practice Address - Phone:215-474-1700
Practice Address - Fax:215-474-0100
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-10
Last Update Date:2020-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP438637183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist