Healthcare Provider Details

I. General information

NPI: 1124212949
Provider Name (Legal Business Name): THELMA A. CANNON PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8707 CHAPEL DR
ANNANDALE VA
22003-3621
US

IV. Provider business mailing address

8707 CHAPEL DR
ANNANDALE VA
22003-3621
US

V. Phone/Fax

Practice location:
  • Phone: 703-978-2797
  • Fax:
Mailing address:
  • Phone: 703-978-2797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202010199
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number0202010199
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: