Provider Demographics
NPI:1578623674
Name:EVANS, CHARLES EUBIE JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EUBIE
Last Name:EVANS
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 MICHAELS RD
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-6721
Mailing Address - Country:US
Mailing Address - Phone:336-284-4292
Mailing Address - Fax:
Practice Address - Street 1:141 MARGINAL ST
Practice Address - Street 2:
Practice Address - City:COOLEEMEE
Practice Address - State:NC
Practice Address - Zip Code:27014
Practice Address - Country:US
Practice Address - Phone:336-284-2537
Practice Address - Fax:336-284-2538
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4791183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0305060Medicaid