Provider Demographics
NPI:1811272065
Name:EVANGELISTA, LEA CAPUNO (RPH)
Entity type:Individual
Prefix:MRS
First Name:LEA
Middle Name:CAPUNO
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9728 WINTER GARDENS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040
Mailing Address - Country:US
Mailing Address - Phone:619-938-0069
Mailing Address - Fax:619-938-9565
Practice Address - Street 1:9728 WINTER GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040
Practice Address - Country:US
Practice Address - Phone:619-938-0069
Practice Address - Fax:619-938-9565
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH62579183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist