Provider Demographics
NPI:1760085005
Name:CONNER, MELISSA BONNER
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:BONNER
Last Name:CONNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:39813-0096
Mailing Address - Country:US
Mailing Address - Phone:229-317-2891
Mailing Address - Fax:
Practice Address - Street 1:11685 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-2573
Practice Address - Country:US
Practice Address - Phone:229-723-4274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022039183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist