Provider Demographics
NPI:1588756498
Name:EVANS, MELISSA
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:
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 1:2137 N WYGANT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3461
Mailing Address - Country:US
Mailing Address - Phone:503-288-1019
Mailing Address - Fax:
Practice Address - Street 1:6400 N INTERSTATE AVE
Practice Address - Street 2:PHARMACY
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-4834
Practice Address - Country:US
Practice Address - Phone:503-467-4848
Practice Address - Fax:503-808-9911
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-0010267183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT-0010267OtherPHARMACY TECH. LICENCE