Provider Demographics
NPI:1619311172
Name:EVANS, PHILLIP KENNETH (PHARM D)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:KENNETH
Last Name:EVANS
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29991 CANYON HILLS RD
Mailing Address - Street 2:SUITE 1709-350
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-2578
Mailing Address - Country:US
Mailing Address - Phone:626-543-4970
Mailing Address - Fax:
Practice Address - Street 1:29991 CANYON HILLS RD
Practice Address - Street 2:SUITE 1709-350
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-2578
Practice Address - Country:US
Practice Address - Phone:626-543-4970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28446183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist