Provider Demographics
NPI:1619666443
Name:CEVALLOS, CHRISTIAN OSCAR
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:OSCAR
Last Name:CEVALLOS
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 1:130 FENWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ATCO
Mailing Address - State:NJ
Mailing Address - Zip Code:08004-3017
Mailing Address - Country:US
Mailing Address - Phone:856-264-9568
Mailing Address - Fax:
Practice Address - Street 1:111 ROUTE 73
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9573
Practice Address - Country:US
Practice Address - Phone:856-768-1801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04305200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist