Provider Demographics
NPI:1669018073
Name:GEORGE, BAN
Entity Type:Individual
Prefix:
First Name:BAN
Middle Name:
Last Name:GEORGE
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 1:40399 GRAND RIVER AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2123
Mailing Address - Country:US
Mailing Address - Phone:248-536-1545
Mailing Address - Fax:
Practice Address - Street 1:40399 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2123
Practice Address - Country:US
Practice Address - Phone:248-536-1545
Practice Address - Fax:248-536-1570
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030976183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist