Provider Demographics
NPI:1275240780
Name:KEVIN CONCANNON LLC
Entity Type:Organization
Organization Name:KEVIN CONCANNON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONCANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-730-7575
Mailing Address - Street 1:4840 E SALIDA DEL SOL PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-5410
Mailing Address - Country:US
Mailing Address - Phone:520-730-7575
Mailing Address - Fax:
Practice Address - Street 1:2500 W TRENTON RD STE 12
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-8023
Practice Address - Country:US
Practice Address - Phone:520-730-7575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEVIN CONCANNON LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy