Healthcare Provider Details

I. General information

NPI: 1265940407
Provider Name (Legal Business Name): COURTNEY BANNISTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4339 EBENEZER RD
BALTIMORE MD
21236-2143
US

IV. Provider business mailing address

5909 WESTERN RUN DR APT B
BALTIMORE MD
21209-4037
US

V. Phone/Fax

Practice location:
  • Phone: 410-529-6171
  • Fax:
Mailing address:
  • Phone: 202-352-2689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number25506
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: