Provider Demographics
NPI:1073693776
Name:BANNER, ALAN GREY (RPH)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:GREY
Last Name:BANNER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 MORNING DOVE LN
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-2709
Mailing Address - Country:US
Mailing Address - Phone:704-876-8707
Mailing Address - Fax:704-878-6684
Practice Address - Street 1:3478 E BROAD ST
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4523
Practice Address - Country:US
Practice Address - Phone:704-878-6681
Practice Address - Fax:704-878-6684
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC05610183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0496471Medicaid
NC770-1799Medicare ID - Type UnspecifiedN.C. MEDICARE PROVIDER