Provider Demographics
NPI:1992306591
Name:TAM, CONNIE DEVERELL (PHARMD RPH)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:DEVERELL
Last Name:TAM
Suffix:
Gender:F
Credentials:PHARMD RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WALMART PHARMACY #1658
Mailing Address - Street 2:2205 HARRISON RD
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824
Mailing Address - Country:US
Mailing Address - Phone:706-595-0180
Mailing Address - Fax:706-595-6037
Practice Address - Street 1:WALMART PHARMACY #1658
Practice Address - Street 2:2205 HARRISON RD
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824
Practice Address - Country:US
Practice Address - Phone:706-595-0180
Practice Address - Fax:706-595-6037
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH017004183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist