Provider Demographics
NPI:1770808214
Name:CONDO, DEBORAH MARIE
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:MARIE
Last Name:CONDO
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 1:2517 OVERBROOK CIR NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-2066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1802 DECATUR PIKE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-4984
Practice Address - Country:US
Practice Address - Phone:423-744-0282
Practice Address - Fax:423-745-9653
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-27
Last Update Date:2010-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33426183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist