Provider Demographics
NPI:1679177943
Name:LANE, EVAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:LANE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30204-1541
Mailing Address - Country:US
Mailing Address - Phone:770-358-4600
Mailing Address - Fax:
Practice Address - Street 1:622 ROSE AVE
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30204-1541
Practice Address - Country:US
Practice Address - Phone:770-358-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029285183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist