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General NPI Number Information
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NPI Number | 1689111023
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Entity Type | Individual
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Provider Name | RAMON RUSSELL BANISTER PHARMD
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Gender | Male
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Dates
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Enumeration Date | 01/24/2017
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Last Update Date | 01/24/2017
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Provider Practice Location Address
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Address Line | 1154 LAWRENCEVILLE HWY INGLES MARKETS
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-5817
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Country | US
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Telephone | 678-985-2654
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Fax |
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Provider Business Mailing Address
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Address Line | 6472 BELLEVUE DR SW
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City | CONYERS
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State | GA
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Zip | 30094-4779
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Country | US
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Telephone | 404-433-7759
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | RPH020018
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License Number State | GA
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