Provider Demographics
NPI:1003008277
Name:BANNER HEALTH
Entity Type:Organization
Organization Name:BANNER HEALTH
Other - Org Name:FAIRBANKS INFUSION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:COTTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:907-458-5621
Mailing Address - Street 1:1650 COWLES ST
Mailing Address - Street 2:DEPT 41B
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5925
Mailing Address - Country:US
Mailing Address - Phone:907-458-5621
Mailing Address - Fax:907-458-5622
Practice Address - Street 1:1650 COWLES ST
Practice Address - Street 2:DEPT 41B
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5925
Practice Address - Country:US
Practice Address - Phone:907-458-5621
Practice Address - Fax:907-458-5622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4233336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPH7755Medicaid
AK423OtherSTATE PHARMACY LICENSE
0227721OtherNCPDP
0227721OtherNCPDP