Provider Demographics
NPI:1023368784
Name:GANNON, MARK SEAN (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:SEAN
Last Name:GANNON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91912-0517
Mailing Address - Country:US
Mailing Address - Phone:858-243-7343
Mailing Address - Fax:
Practice Address - Street 1:7018 BLAIR RD
Practice Address - Street 2:
Practice Address - City:CALIPATRIA
Practice Address - State:CA
Practice Address - Zip Code:92233-9633
Practice Address - Country:US
Practice Address - Phone:760-604-2224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50696183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist