MEDICARE: BRENDA LILES CONRADI R.PH.

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	11750	AL

General Provider Information

NPI Number	:	1912205857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA LILES CONRADI R.PH.

Provider Business Mailing Address
First Line	:	641 OLLIE AVE
Second Line	:
City	:	CLANTON
State	:	AL
Zip	:	35045-2236
Country	:	US
Telephone Number	:	205-755-5879
Fax Number	:	205-280-6975

Provider Business Practice Location Address
First Line	:	641 OLLIE AVE
Second Line	:
City	:	CLANTON
State	:	AL
Zip	:	35045-2236
Country	:	US
Telephone Number	:	205-755-5879
Fax Number	:	205-280-6975

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

Provider Enumeration Date	:	03/01/2011
Last Update Date	:	03/01/2011

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