Provider Demographics
NPI:1760906242
Name:BANKS, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BANKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 FOREST DR APT 2213
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-6502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 BROAD ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-2225
Practice Address - Country:US
Practice Address - Phone:803-432-5103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37089183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist