Provider Demographics
NPI:1588866206
Name:BANVERA LLC
Entity type:Organization
Organization Name:BANVERA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BANYO
Authorized Official - Middle Name:
Authorized Official - Last Name:NDANGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:757-599-9643
Mailing Address - Street 1:956 J CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1043
Mailing Address - Country:US
Mailing Address - Phone:757-599-9643
Mailing Address - Fax:757-599-9647
Practice Address - Street 1:956 J CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1043
Practice Address - Country:US
Practice Address - Phone:757-599-9643
Practice Address - Fax:757-599-9647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA332B00000X
VA02010041653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010262615Medicaid
VA4840078OtherNCPDP#
VA4840078OtherNCPDP#
VA010262615Medicaid
VA5966670001Medicare NSC