Basic Information
| Provider Information | |||||||||
| NPI: | 1083035117 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BANNER PHARMACY SERVICES LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BANNER FAMILY PHARMACY - DESERT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 N CENTRAL AVE STE 160 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027474000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1400 S DOBSON RD | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852024707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804124250 | ||||||||
| FaxNumber: | 4804124252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2013 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LARRAWAY | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6027474000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | Y005805 | AZ | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 896515 | 05 | AZ | MEDICAID | 2145016 | 01 | PK | OTHER |