Basic Information
| Provider Information | |||||||||
| NPI: | 1396055349 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BANNER FAMILY PHARMACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 N 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062837 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 E MCDOWELL RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028395972 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2010 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | DAHLEN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6027474000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BANNER HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.