Healthcare Provider Details

I. General information

NPI: 1285232090
Provider Name (Legal Business Name): CHARLES CANNON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 MEMORIAL DR
WAYCROSS GA
31501-1949
US

IV. Provider business mailing address

1606 MEMORIAL DR
WAYCROSS GA
31501-1949
US

V. Phone/Fax

Practice location:
  • Phone: 912-287-2277
  • Fax:
Mailing address:
  • Phone: 912-287-2277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number025057
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: