Provider Demographics
NPI:1689111023
Name:BANISTER, RAMON RUSSELL (PHARMD)
Entity Type:Individual
Prefix:
First Name:RAMON
Middle Name:RUSSELL
Last Name:BANISTER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6472 BELLEVUE DR SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-4779
Mailing Address - Country:US
Mailing Address - Phone:404-433-7759
Mailing Address - Fax:
Practice Address - Street 1:1154 LAWRENCEVILLE HWY
Practice Address - Street 2:INGLES MARKETS
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-5817
Practice Address - Country:US
Practice Address - Phone:678-985-2654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH020018183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH020018OtherPHARMACIST LICENSE
GA196123OtherNABP