MEDICARE: CONNOR DALE WILLYARD PHARM D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	RPH029677	GA

General Provider Information

NPI Number	:	1295479301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNOR DALE WILLYARD PHARM D

Provider Business Mailing Address
First Line	:	1910 MOUNT VERNON ALSTON RD
Second Line	:
City	:	AILEY
State	:	GA
Zip	:	30410-2446
Country	:	US
Telephone Number	:	912-253-2088
Fax Number	:

Provider Business Practice Location Address
First Line	:	214 S MAIN ST
Second Line	:
City	:	REIDSVILLE
State	:	GA
Zip	:	30453-4602
Country	:	US
Telephone Number	:	912-557-4701
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2022
Last Update Date	:	04/25/2022

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