Provider Demographics
NPI:1639057847
Name:PRODUCE PHARMACY LLC
Entity type:Organization
Organization Name:PRODUCE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:BANNISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-534-1797
Mailing Address - Street 1:21321 E OCOTILLO RD STE 104
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-5993
Mailing Address - Country:US
Mailing Address - Phone:480-534-1797
Mailing Address - Fax:
Practice Address - Street 1:21321 E OCOTILLO RD STE 104
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-5993
Practice Address - Country:US
Practice Address - Phone:480-534-1797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy