Provider Demographics
NPI:1164875340
Name:PANTHER HEALTH, LLC
Entity Type:Organization
Organization Name:PANTHER HEALTH, LLC
Other - Org Name:CANNON PHARMACY MOORESVILLE DME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:YANICKO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:704-658-9870
Mailing Address - Street 1:521 E PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-8071
Mailing Address - Country:US
Mailing Address - Phone:704-658-9870
Mailing Address - Fax:704-658-9871
Practice Address - Street 1:521 E PLAZA DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-8071
Practice Address - Country:US
Practice Address - Phone:704-658-9870
Practice Address - Fax:704-658-9871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-22
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1225412562332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1225412562Medicaid