1992306591 NPI number — CONNIE DEVERELL TAM PHARM.D. RPH

Table of content: CONNIE DEVERELL TAM PHARM.D. RPH (NPI 1992306591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992306591 NPI number — CONNIE DEVERELL TAM PHARM.D. RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAM
Provider First Name:
CONNIE
Provider Middle Name:
DEVERELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D. RPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992306591
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
WALMART PHARMACY #1658
Provider Second Line Business Mailing Address:
2205 HARRISON RD
Provider Business Mailing Address City Name:
THOMSON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-595-0180
Provider Business Mailing Address Fax Number:
706-595-6037

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WALMART PHARMACY #1658
Provider Second Line Business Practice Location Address:
2205 HARRISON RD
Provider Business Practice Location Address City Name:
THOMSON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-595-0180
Provider Business Practice Location Address Fax Number:
706-595-6037
Provider Enumeration Date:
11/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RPH017004 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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