Provider Demographics
NPI:1457695744
Name:O'BANNON, EDDIE (PD)
Entity Type:Individual
Prefix:MR
First Name:EDDIE
Middle Name:
Last Name:O'BANNON
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 HIGHWAY 51 S
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-1737
Mailing Address - Country:US
Mailing Address - Phone:662-280-7457
Mailing Address - Fax:
Practice Address - Street 1:2260 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-1737
Practice Address - Country:US
Practice Address - Phone:662-280-7457
Practice Address - Fax:662-280-7457
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-08835183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist