Provider Demographics
NPI:1962523332
Name:BANAHAN, JOHN PATRICK
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:PATRICK
Last Name:BANAHAN
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 1:11427 LAKE LUCAYA DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-4105
Mailing Address - Country:US
Mailing Address - Phone:787-340-0012
Mailing Address - Fax:813-677-8890
Practice Address - Street 1:11427 LAKE LUCAYA DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-4105
Practice Address - Country:US
Practice Address - Phone:787-340-0012
Practice Address - Fax:813-677-8890
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3792183500000X
FLPS 54927183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist