Healthcare Provider Details

I. General information

NPI: 1376451815
Provider Name (Legal Business Name): DESTINEE EVE HUNNICUTT FANNON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 WOODLAND DR SW
WISE VA
24293-4605
US

IV. Provider business mailing address

6240 STEPHENS RD
WISE VA
24293-7600
US

V. Phone/Fax

Practice location:
  • Phone: 276-328-4651
  • Fax:
Mailing address:
  • Phone: 276-870-2275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202223872
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: