1972939882 NPI number — BANNER FAMILY PHARMACY

Table of content: (NPI 1972939882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972939882 NPI number — BANNER FAMILY PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BANNER FAMILY PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BANNER FAMILY PHARMACY - ESTRELLA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972939882
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 E MCDOWELL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85006-2612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-327-6170
Provider Business Mailing Address Fax Number:
623-327-6171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9201 W THOMAS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85037-3332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-327-6170
Provider Business Practice Location Address Fax Number:
623-327-6171
Provider Enumeration Date:
09/24/2013

Additional Information

Authorized Official

Authorized Official Last Name:
KRMPOTIC
Authorized Official First Name:
DEB
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
623-327-5001

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  Y005712 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 851577 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2142167 . This is a "PK" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com