Individual
DR. KENNON LATRELL TYRE III
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
PHARM.D.
Contact information
Practice address
410 DARLING AVE, PHARMACY DEPARTMENT, WAYCROSS, GA 31501-5246
(912) 287-2640
(912) 287-2642
Mailing address
937 DOGWOOD DR, BLACKSHEAR, GA 31516-2302
(912) 449-8634
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
18517
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
18517
GA LICENSE
GA
Enumeration date
10/27/2005
Last updated
07/08/2007
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