Provider Demographics
NPI:1609426477
Name:EVANS, MICHAEL THOMAS
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:EVANS
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 1:4900 WYALUSING AVE RM 106108
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-5127
Mailing Address - Country:US
Mailing Address - Phone:215-764-6519
Mailing Address - Fax:215-477-1537
Practice Address - Street 1:4900 WYALUSING AVE RM 106108
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-5127
Practice Address - Country:US
Practice Address - Phone:215-764-6519
Practice Address - Fax:215-477-1537
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP030590L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024286690019Medicaid