Provider Demographics
NPI:1295388015
Name:O'DANIELS, CONNOR JARED (PHARMD)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:JARED
Last Name:O'DANIELS
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 1:4401 SHALLOWFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3193
Mailing Address - Country:US
Mailing Address - Phone:770-640-7742
Mailing Address - Fax:
Practice Address - Street 1:4401 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3193
Practice Address - Country:US
Practice Address - Phone:770-640-7742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-21
Last Update Date:2020-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH031466183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist