Basic Information
| Provider Information | |||||||||
| NPI: | 1578996823 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BANNER FAMILY PHARMACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 N 12T ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85006 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5555 W THUNDERBIRD RD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853064622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028652378 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2013 | ||||||||
| LastUpdateDate: | 08/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | DAHLEN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| 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 | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.