Provider Demographics
NPI:1720126741
Name:CANNON, GEORGE ROBERT JR
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:ROBERT
Last Name:CANNON
Suffix:JR
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 1:112 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2537
Mailing Address - Country:US
Mailing Address - Phone:334-347-2506
Mailing Address - Fax:
Practice Address - Street 1:112 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2537
Practice Address - Country:US
Practice Address - Phone:334-347-2506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6979183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist