Provider Demographics
NPI:1538513742
Name:BANNER PHARMACY SERVICES LLC
Entity type:Organization
Organization Name:BANNER PHARMACY SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-747-4197
Mailing Address - Street 1:2901 N CENTRAL AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2702
Mailing Address - Country:US
Mailing Address - Phone:602-747-4000
Mailing Address - Fax:
Practice Address - Street 1:2555 E 13TH ST STE 125
Practice Address - Street 2:SUITE 125
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-5135
Practice Address - Country:US
Practice Address - Phone:970-820-4300
Practice Address - Fax:970-820-4303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-14
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
COPDO.16800001133336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152767OtherPK