Provider Demographics
NPI:1184499709
Name:BANANA, MAE ANNE SEGOVIA
Entity type:Individual
Prefix:
First Name:MAE ANNE
Middle Name:SEGOVIA
Last Name:BANANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:553 REFOSCO CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-4129
Mailing Address - Country:US
Mailing Address - Phone:530-567-9079
Mailing Address - Fax:
Practice Address - Street 1:2590 N TEXAS ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-1606
Practice Address - Country:US
Practice Address - Phone:707-399-9329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-24
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88852183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist