Provider Demographics
NPI:1588092282
Name:BANNER FAMILY PHARMACY
Entity type:Organization
Organization Name:BANNER FAMILY PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHCY OPS SENIOR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EVELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-412-4250
Mailing Address - Street 1:1111 E MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2612
Mailing Address - Country:US
Mailing Address - Phone:602-839-2000
Mailing Address - Fax:
Practice Address - Street 1:1400 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4707
Practice Address - Country:US
Practice Address - Phone:480-412-4250
Practice Address - Fax:480-412-4252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0058053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ863491Medicaid
2142567OtherPK