Provider Demographics
NPI:1295479301
Name:WILLYARD, CONNOR DALE (PHARM D)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:DALE
Last Name:WILLYARD
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 MOUNT VERNON ALSTON RD
Mailing Address - Street 2:
Mailing Address - City:AILEY
Mailing Address - State:GA
Mailing Address - Zip Code:30410-2446
Mailing Address - Country:US
Mailing Address - Phone:912-253-2088
Mailing Address - Fax:
Practice Address - Street 1:214 S MAIN ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30453-4602
Practice Address - Country:US
Practice Address - Phone:912-557-4701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH029677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist