Basic Information
| Provider Information | |||||||||
| NPI: | 1407461890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANGELISTA CORDON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANTONETTE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CORDON | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | ANTONETTE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHARMD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 380 MATHER ST APT 6414 | ||||||||
| Address2: | |||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065143199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2013658136 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 267 GRANT ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066102870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2020 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 0202217006 | VA | N | Pharmacy Service Providers | Pharmacist | 183500000X | PTP.0000548 | CT | N | Pharmacy Service Providers | Pharmacist | 183500000X | 28RI03890300 | NJ | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | PTP.0000548 | 01 | CT | CONNECTICUT BOARD OF PHARMACY | OTHER | 0202217006 | 01 | VA | VIRGINIA BOARD OF PHARMACY | OTHER | 28RI03890300 | 01 | NJ | NEW JERSEY BOARD OF PHARMACY | OTHER |