Provider Demographics
NPI:1700487972
Name:EVANS, SUSAN MARIE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
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 1:15426 CONRAD SPRING RD
Mailing Address - Street 2:
Mailing Address - City:BOYDS
Mailing Address - State:MD
Mailing Address - Zip Code:20841-3001
Mailing Address - Country:US
Mailing Address - Phone:301-385-7785
Mailing Address - Fax:
Practice Address - Street 1:18331 LEAMAN FARM RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-2904
Practice Address - Country:US
Practice Address - Phone:301-528-2764
Practice Address - Fax:844-411-6294
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12439183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist