Provider Demographics
NPI:1942779194
Name:BANNON, JON PAUL
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:PAUL
Last Name:BANNON
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 1:90 CARRS HL
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16830-8200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 N CENTRE ST
Practice Address - Street 2:
Practice Address - City:PHILIPSBURG
Practice Address - State:PA
Practice Address - Zip Code:16866-2146
Practice Address - Country:US
Practice Address - Phone:814-342-1752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP441309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist