Provider Demographics
NPI:1619012382
Name:EVANSDALE PHARMACY, INC.
Entity Type:Organization
Organization Name:EVANSDALE PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RIC
Authorized Official - Middle Name:E
Authorized Official - Last Name:FOREMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:319-233-3395
Mailing Address - Street 1:3506 LAFAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:EVANSDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50707-1025
Mailing Address - Country:US
Mailing Address - Phone:319-233-3395
Mailing Address - Fax:
Practice Address - Street 1:3506 LAFAYETTE RD
Practice Address - Street 2:
Practice Address - City:EVANSDALE
Practice Address - State:IA
Practice Address - Zip Code:50707-1025
Practice Address - Country:US
Practice Address - Phone:319-233-3395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA5133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0076547Medicaid