Provider Demographics
NPI:1063804094
Name:ANDERSON, EVAN DARWIN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:DARWIN
Last Name:ANDERSON
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 1:1740 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-1044
Mailing Address - Country:US
Mailing Address - Phone:912-338-9127
Mailing Address - Fax:912-338-9847
Practice Address - Street 1:1740 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-1044
Practice Address - Country:US
Practice Address - Phone:912-338-9127
Practice Address - Fax:912-338-9847
Is Sole Proprietor?:No
Enumeration Date:2015-02-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH025602183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist