Provider Demographics
NPI:1972939882
Name:BANNER FAMILY PHARMACY
Entity type:Organization
Organization Name:BANNER FAMILY PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEB
Authorized Official - Middle Name:
Authorized Official - Last Name:KRMPOTIC
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:623-327-5001
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:623-327-6170
Mailing Address - Fax:623-327-6171
Practice Address - Street 1:9201 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3332
Practice Address - Country:US
Practice Address - Phone:623-327-6170
Practice Address - Fax:623-327-6171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0057123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ851577Medicaid
2142167OtherPK