Provider Demographics
NPI:1407137524
Name:CONLON, MARY ARCHER (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ARCHER
Last Name:CONLON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2633 GREGOR MCGREGOR BLVD
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-2246
Mailing Address - Country:US
Mailing Address - Phone:678-778-8913
Mailing Address - Fax:
Practice Address - Street 1:2101 SADLER RD
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4452
Practice Address - Country:US
Practice Address - Phone:904-277-9615
Practice Address - Fax:904-261-4838
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH021638183500000X
FLPS41149183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH021638OtherSTATE BOARD OF PHARMACY
FLPS41149OtherSTATE BOARD OF PHARMACY