Provider Demographics
NPI:1851690028
Name:EVANS, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 WOODLAWN ST
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18509-1534
Mailing Address - Country:US
Mailing Address - Phone:570-346-1460
Mailing Address - Fax:
Practice Address - Street 1:1650 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLYPHANT
Practice Address - State:PA
Practice Address - Zip Code:18447-1334
Practice Address - Country:US
Practice Address - Phone:570-489-8834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-27
Last Update Date:2011-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP437681183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist