Provider Demographics
NPI:1083960504
Name:CARROLL, MACON DEVAUGHN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MACON
Middle Name:DEVAUGHN
Last Name:CARROLL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 DEXTER L WOODS MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38485-2416
Mailing Address - Country:US
Mailing Address - Phone:931-722-5466
Mailing Address - Fax:931-722-9495
Practice Address - Street 1:107 JV MANGUBAT DR
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:TN
Practice Address - Zip Code:38485-2440
Practice Address - Country:US
Practice Address - Phone:931-722-2296
Practice Address - Fax:931-722-3464
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000036920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36920OtherBOARD OF PHARMACY LICENSE