Provider Demographics
NPI:1134348576
Name:BANOUB, PHYLLIS A (RPH)
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:A
Last Name:BANOUB
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 VIRGIL RD
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07648-1245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 RIVER RD
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:NJ
Practice Address - Zip Code:07646-3127
Practice Address - Country:US
Practice Address - Phone:201-967-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01596500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist