Provider Demographics
NPI:1356942072
Name:CANNON, MARTY WAYNE (PHARM D)
Entity type:Individual
Prefix:
First Name:MARTY
Middle Name:WAYNE
Last Name:CANNON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 HWY 25B
Mailing Address - Street 2:
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543
Mailing Address - Country:US
Mailing Address - Phone:501-362-2864
Mailing Address - Fax:501-362-1984
Practice Address - Street 1:1500 HWY 25B
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543
Practice Address - Country:US
Practice Address - Phone:501-362-2864
Practice Address - Fax:501-362-1984
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD08068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist