Healthcare Provider Details

I. General information

NPI: 1386717692
Provider Name (Legal Business Name): WAYMON M CANNON PHARM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 MAC THOMPSON ROAD
COCHRAN GA
31014
US

IV. Provider business mailing address

332 MAC THOMPSON ROAD
COCHRAN GA
31014
US

V. Phone/Fax

Practice location:
  • Phone: 478-934-4299
  • Fax: 478-274-0053
Mailing address:
  • Phone: 478-934-4299
  • Fax: 478-274-0053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number011472
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: