Provider Demographics
NPI:1659876605
Name:BANKS, FAIRVEOLA
Entity Type:Individual
Prefix:
First Name:FAIRVEOLA
Middle Name:
Last Name:BANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3628 E IMPERIAL HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-2600
Mailing Address - Country:US
Mailing Address - Phone:310-637-2006
Mailing Address - Fax:
Practice Address - Street 1:3628 E IMPERIAL HWY STE 102
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2600
Practice Address - Country:US
Practice Address - Phone:310-637-2006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
48607333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy