Provider Demographics
NPI:1700469749
Name:CANNON, CHARLEASE DEANN
Entity Type:Individual
Prefix:
First Name:CHARLEASE
Middle Name:DEANN
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 DANCYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:TN
Mailing Address - Zip Code:38069-4664
Mailing Address - Country:US
Mailing Address - Phone:901-491-2879
Mailing Address - Fax:
Practice Address - Street 1:1100 S DUPREE AVE
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38012-3234
Practice Address - Country:US
Practice Address - Phone:731-772-6283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000043516183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist