Provider Demographics
NPI:1295554442
Name:EVANS, MONICA
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:
Other - Last Name:VIDAL LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:856 SHADOW RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-2513
Mailing Address - Country:US
Mailing Address - Phone:619-754-5386
Mailing Address - Fax:
Practice Address - Street 1:3030 CHILDRENS WAY STE 108
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4226
Practice Address - Country:US
Practice Address - Phone:858-966-4060
Practice Address - Fax:858-966-5995
Is Sole Proprietor?:No
Enumeration Date:2024-10-05
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59753183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist