Provider Demographics
NPI:1871615807
Name:FANNON, ROBERT L
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:L
Last Name:FANNON
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:BX 1407
Mailing Address - Street 2:
Mailing Address - City:LAFOLLETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37766
Mailing Address - Country:US
Mailing Address - Phone:423-562-5235
Mailing Address - Fax:423-566-2212
Practice Address - Street 1:502 W CENTRAL AVE
Practice Address - Street 2:RIGGS DRUG
Practice Address - City:LAFOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766
Practice Address - Country:US
Practice Address - Phone:423-562-5235
Practice Address - Fax:423-566-2212
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3575183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3575OtherSTATE LIC