Provider Demographics
NPI:1386717692
Name:CANNON, WAYMON M (PHARM)
Entity type:Individual
Prefix:PROF
First Name:WAYMON
Middle Name:M
Last Name:CANNON
Suffix:
Gender:M
Credentials:PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 MAC THOMPSON ROAD
Mailing Address - Street 2:
Mailing Address - City:COCHRAN
Mailing Address - State:GA
Mailing Address - Zip Code:31014
Mailing Address - Country:US
Mailing Address - Phone:478-934-4299
Mailing Address - Fax:478-274-0053
Practice Address - Street 1:332 MAC THOMPSON ROAD
Practice Address - Street 2:
Practice Address - City:COCHRAN
Practice Address - State:GA
Practice Address - Zip Code:31014
Practice Address - Country:US
Practice Address - Phone:478-934-4299
Practice Address - Fax:478-274-0053
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist