Healthcare Provider Details

I. General information

NPI: 1013483213
Provider Name (Legal Business Name): DAVID CANNON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2018
Last Update Date: 10/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WADE AVE
CATONSVILLE MD
21228-4663
US

IV. Provider business mailing address

9082 FLAMEPOOL WAY
COLUMBIA MD
21045-2901
US

V. Phone/Fax

Practice location:
  • Phone: 410-402-7696
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number20367
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: