Provider Demographics
NPI:1992395495
Name:BANNAN, PHIL (PHARMD)
Entity Type:Individual
Prefix:
First Name:PHIL
Middle Name:
Last Name:BANNAN
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 1:26 VALERIE DR
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02762-1404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26 VALERIE DR
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:MA
Practice Address - Zip Code:02762-1404
Practice Address - Country:US
Practice Address - Phone:508-243-3576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH234698183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist