Provider Demographics
NPI:1821211582
Name:FANNON, BILL R JR (DPH)
Entity type:Individual
Prefix:MR
First Name:BILL
Middle Name:R
Last Name:FANNON
Suffix:JR
Gender:M
Credentials:DPH
Other - Prefix:MR
Other - First Name:WILLIAM
Other - Middle Name:R
Other - Last Name:FANNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPH
Mailing Address - Street 1:PO BOX 140
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37879
Mailing Address - Country:US
Mailing Address - Phone:423-562-3115
Mailing Address - Fax:423-566-2212
Practice Address - Street 1:502 WEST CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766
Practice Address - Country:US
Practice Address - Phone:423-526-5235
Practice Address - Fax:423-566-2212
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3425183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist