Provider Demographics
NPI:1992585756
Name:MANCHA, EVELYN ELIDE (PHARMD)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:ELIDE
Last Name:MANCHA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2373 HALL AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-8420
Mailing Address - Country:US
Mailing Address - Phone:209-601-0572
Mailing Address - Fax:
Practice Address - Street 1:2040 EAST MARIPOSA ROAD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205
Practice Address - Country:US
Practice Address - Phone:209-601-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88427183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist