Provider Demographics
NPI:1821398959
Name:TUCKER, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:TUCKER
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 1:3663 BRIARPARK DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-5205
Mailing Address - Country:US
Mailing Address - Phone:713-268-3630
Mailing Address - Fax:623-869-1717
Practice Address - Street 1:10228 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-8087
Practice Address - Country:US
Practice Address - Phone:281-504-0285
Practice Address - Fax:281-504-0287
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45642183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist