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General NPI Number Information
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NPI Number | 1629068895
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Entity Type | Individual
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Provider Name | KENNON LATRELL TYRE III PHARM.D.
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Gender | Male
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Dates
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Enumeration Date | 10/27/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 410 DARLING AVE PHARMACY DEPARTMENT
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City | WAYCROSS
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State | GA
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Zip | 31501-5246
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Country | US
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Telephone | 912-287-2640
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Fax | 912-287-2642
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Provider Business Mailing Address
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Address Line | 937 DOGWOOD DR
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City | BLACKSHEAR
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State | GA
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Zip | 31516-2302
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Country | US
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Telephone | 912-449-8634
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 18517
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License Number State | GA
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