Provider Demographics
NPI:1134003320
Name:CONDRA, ALTON PORTER III
Entity type:Individual
Prefix:
First Name:ALTON
Middle Name:PORTER
Last Name:CONDRA
Suffix:III
Gender:M
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 17740
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-0740
Mailing Address - Country:US
Mailing Address - Phone:404-668-2768
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 17740
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-0740
Practice Address - Country:US
Practice Address - Phone:404-668-2768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-01
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH018261183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist