Provider Demographics
NPI:1457750614
Name:CANNON, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:CANNON
Suffix:
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 1:1114 RUSTLING OAKS DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VIEW
Mailing Address - State:TN
Mailing Address - Zip Code:37146-7046
Mailing Address - Country:US
Mailing Address - Phone:615-415-4646
Mailing Address - Fax:
Practice Address - Street 1:1114 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38012-2621
Practice Address - Country:US
Practice Address - Phone:731-772-1170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-13
Last Update Date:2020-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38490183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist