Basic Information
| Provider Information | |||||||||
| NPI: | 1235692252 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONRAD | ||||||||
| FirstName: | ALLEN | ||||||||
| MiddleName: | JOHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1318 W 51ST ST | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528063669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5635057841 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5811 ELMORE AVE | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528073513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633594874 | ||||||||
| FaxNumber: | 5633594876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2019 | ||||||||
| LastUpdateDate: | 04/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 122 | IA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.