Provider Demographics
NPI:1316368459
Name:BANNER PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:BANNER PHARMACY SERVICES LLC
Other - Org Name:BANNER FAMILY PHARMACY - UNIVERSITY MEDICAL CENTER PHOENIX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LARAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-747-4000
Mailing Address - Street 1:2910 N CENTRAL AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2704
Mailing Address - Country:US
Mailing Address - Phone:602-747-4000
Mailing Address - Fax:
Practice Address - Street 1:1111 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2612
Practice Address - Country:US
Practice Address - Phone:602-839-2300
Practice Address - Fax:602-839-4226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-16
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
AZY0058063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145019OtherPK
AZ896498Medicaid