Provider Demographics
NPI:1700912698
Name:BANJARA, NIRAJ D (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:NIRAJ
Middle Name:D
Last Name:BANJARA
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8880 FALCON POINTE LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-1473
Mailing Address - Country:US
Mailing Address - Phone:239-466-3916
Mailing Address - Fax:941-505-9657
Practice Address - Street 1:27680 BERMONT ROAD
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33982
Practice Address - Country:US
Practice Address - Phone:941-505-9583
Practice Address - Fax:941-505-9657
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0556050458Medicare ID - Type Unspecified