Provider Demographics
NPI:1992074173
Name:EVANICK, MICHAEL CHARLES (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:EVANICK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 SE 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-2509
Mailing Address - Country:US
Mailing Address - Phone:239-898-8170
Mailing Address - Fax:
Practice Address - Street 1:611 BURNT STORE RD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-1708
Practice Address - Country:US
Practice Address - Phone:239-690-4039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-18
Last Update Date:2011-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS35922183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist