Provider Demographics
NPI:1992274641
Name:HENRY, EVAN JAMES
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:JAMES
Last Name:HENRY
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 1:108 BELVEDERE ST
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-2702
Mailing Address - Country:US
Mailing Address - Phone:717-713-4648
Mailing Address - Fax:
Practice Address - Street 1:316 WALNUT ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:PA
Practice Address - Zip Code:17074-1524
Practice Address - Country:US
Practice Address - Phone:717-567-6047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-23
Last Update Date:2018-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP452628183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist