Provider Demographics
NPI:1518550318
Name:PHAN, EVELYN
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 GENERAL DANIEL AVE N
Mailing Address - Street 2:
Mailing Address - City:DANIELSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30633-6910
Mailing Address - Country:US
Mailing Address - Phone:706-795-2135
Mailing Address - Fax:
Practice Address - Street 1:380 GENERAL DANIEL AVE N
Practice Address - Street 2:
Practice Address - City:DANIELSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30633-6910
Practice Address - Country:US
Practice Address - Phone:706-795-2135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH029484183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist