Provider Demographics
NPI:1184919094
Name:CANNON, WILLIAM R II
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:R
Last Name:CANNON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E MIRACLE STRIP PKWY
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1924
Mailing Address - Country:US
Mailing Address - Phone:850-243-9557
Mailing Address - Fax:
Practice Address - Street 1:250 E MIRACLE STRIP PKWY
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1924
Practice Address - Country:US
Practice Address - Phone:850-243-9557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS36509183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist