Provider Demographics
NPI:1417328907
Name:CANNON, JONATHAN ANGUS (PHARMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ANGUS
Last Name:CANNON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 S QUAY PL
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-9338
Mailing Address - Country:US
Mailing Address - Phone:801-400-6452
Mailing Address - Fax:
Practice Address - Street 1:2720 S QUILLAN ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99337-2404
Practice Address - Country:US
Practice Address - Phone:509-586-1574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60493182183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist