Provider Demographics
NPI:1780284414
Name:BANNER, BRIDGET
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
Last Name:BANNER
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 1:1050 REGIONAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266-3712
Mailing Address - Country:US
Mailing Address - Phone:276-889-3547
Mailing Address - Fax:
Practice Address - Street 1:1050 REGIONAL PARK RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-3712
Practice Address - Country:US
Practice Address - Phone:276-889-3547
Practice Address - Fax:276-889-3595
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204192183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist