Healthcare Provider Details

I. General information

NPI: 1184919094
Provider Name (Legal Business Name): MR. WILLIAM R CANNON II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E MIRACLE STRIP PKWY
MARY ESTHER FL
32569-1924
US

IV. Provider business mailing address

250 E MIRACLE STRIP PKWY
MARY ESTHER FL
32569-1924
US

V. Phone/Fax

Practice location:
  • Phone: 850-243-9557
  • Fax:
Mailing address:
  • Phone: 850-243-9557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS36509
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: