Provider Demographics
NPI:1942389366
Name:CANNON, ELIZABETH C (RPH)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:C
Last Name:CANNON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 4TH ST
Mailing Address - Street 2:P.O. BOX 340
Mailing Address - City:RHINE
Mailing Address - State:GA
Mailing Address - Zip Code:31077-4139
Mailing Address - Country:US
Mailing Address - Phone:229-385-6914
Mailing Address - Fax:229-467-2089
Practice Address - Street 1:201 MAIN ST W
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31001-4211
Practice Address - Country:US
Practice Address - Phone:229-467-2221
Practice Address - Fax:229-467-2089
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011583183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00021007AMedicaid
GA1104126OtherNCPDP NUMBER
GA00021007AMedicaid