Provider Demographics
NPI:1992096200
Name:KINCANNON, TONY RAY
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:RAY
Last Name:KINCANNON
Suffix:
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 1:150 GADDIS RD NW
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-4679
Mailing Address - Country:US
Mailing Address - Phone:770-382-8804
Mailing Address - Fax:
Practice Address - Street 1:954 JOE FRANK HARRIS PKWY SE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2129
Practice Address - Country:US
Practice Address - Phone:770-383-3055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11511183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist