Provider Demographics
NPI:1356434930
Name:EVANS DRUG COMPANY PLLC
Entity type:Organization
Organization Name:EVANS DRUG COMPANY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:PRATER
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:270-472-2421
Mailing Address - Street 1:214 LAKE STREET
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:KY
Mailing Address - Zip Code:42041
Mailing Address - Country:US
Mailing Address - Phone:270-472-2421
Mailing Address - Fax:
Practice Address - Street 1:214 LAKE STREET
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:KY
Practice Address - Zip Code:42041
Practice Address - Country:US
Practice Address - Phone:270-472-2421
Practice Address - Fax:270-472-0103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10684183500000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54035050Medicaid
KY6147390001Medicare NSC