Provider Demographics
NPI:1528375557
Name:SIA, EVELYN R (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:R
Last Name:SIA
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W ANAHEIM ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90745
Mailing Address - Country:US
Mailing Address - Phone:310-830-3100
Mailing Address - Fax:310-830-2009
Practice Address - Street 1:108 W ANAHEIM ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90745
Practice Address - Country:US
Practice Address - Phone:310-830-3100
Practice Address - Fax:310-830-2009
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44116183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA44116Medicaid