Provider Demographics
NPI:1972518579
Name:JOHN DOUGLAS EVANS
Entity Type:Organization
Organization Name:JOHN DOUGLAS EVANS
Other - Org Name:COMMUNITY DRUG PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:615-855-1603
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37070-1267
Mailing Address - Country:US
Mailing Address - Phone:615-855-1603
Mailing Address - Fax:615-855-1695
Practice Address - Street 1:919 CONFERENCE DR
Practice Address - Street 2:UNIT 4
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-1933
Practice Address - Country:US
Practice Address - Phone:615-855-1603
Practice Address - Fax:615-855-1605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN42273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1455058Medicaid
4438758OtherNCPDP PROVIDER IDENTIFICATION NUMBER