Provider Demographics
NPI:1235692252
Name:CONRAD, ALLEN JOHN
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:JOHN
Last Name:CONRAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 W 51ST ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-3669
Mailing Address - Country:US
Mailing Address - Phone:563-505-7841
Mailing Address - Fax:
Practice Address - Street 1:5811 ELMORE AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3513
Practice Address - Country:US
Practice Address - Phone:563-359-4874
Practice Address - Fax:563-359-4876
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist