Provider Demographics
NPI:1164501433
Name:BANISTER, BRADLEY PAUL (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:PAUL
Last Name:BANISTER
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 S ROBINSON AVE
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554-4613
Mailing Address - Country:US
Mailing Address - Phone:580-782-2750
Mailing Address - Fax:580-782-5404
Practice Address - Street 1:1000 S. LOUIS TITTLE
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554
Practice Address - Country:US
Practice Address - Phone:580-782-5400
Practice Address - Fax:580-782-5404
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13420183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist