Healthcare Provider Details

I. General information

NPI: 1780729509
Provider Name (Legal Business Name): DEBORAH TILLERY CONKLE R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 COMER AVE SECOND FLOOR
COLUMBUS GA
31904-8725
US

IV. Provider business mailing address

2407 BROOKWOOD CIR
PHENIX CITY AL
36867-2454
US

V. Phone/Fax

Practice location:
  • Phone: 706-321-3700
  • Fax: 706-321-3751
Mailing address:
  • Phone: 334-297-5681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH12428
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: