Provider Demographics
NPI:1407450273
Name:GANNON, KAITLYN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3604 HOUSEHOLDER ST APT 323
Mailing Address - Street 2:
Mailing Address - City:PIGEON FORGE
Mailing Address - State:TN
Mailing Address - Zip Code:37863-3440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2339 NEWPORT HWY
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37876-2057
Practice Address - Country:US
Practice Address - Phone:865-908-8695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41443183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist