Provider Demographics
NPI:1528043593
Name:BANNER HOME MEDICAL SUPPLY L.L.C
Entity Type:Organization
Organization Name:BANNER HOME MEDICAL SUPPLY L.L.C
Other - Org Name:MARC S. BANNER SR.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRIMARY OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:STEPHAN
Authorized Official - Last Name:BANNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-482-0042
Mailing Address - Street 1:67 E DAYTON YELLOW SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-3445
Mailing Address - Country:US
Mailing Address - Phone:937-754-1210
Mailing Address - Fax:937-482-0041
Practice Address - Street 1:67 E DAYTON YELLOW SPRINGS RD
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-3445
Practice Address - Country:US
Practice Address - Phone:937-754-1210
Practice Address - Fax:937-482-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHHMEP33019332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2561731Medicaid
OH1298040001Medicare ID - Type Unspecified