Provider Demographics
NPI:1063618130
Name:BENTON, LEWIS CALVIN JR (DPH)
Entity type:Individual
Prefix:
First Name:LEWIS
Middle Name:CALVIN
Last Name:BENTON
Suffix:JR
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 HARR TOWN RD
Mailing Address - Street 2:
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-3829
Mailing Address - Country:US
Mailing Address - Phone:423-323-1988
Mailing Address - Fax:423-323-1988
Practice Address - Street 1:1430 VOLUNTEER PKWY
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620
Practice Address - Country:US
Practice Address - Phone:423-968-2222
Practice Address - Fax:423-968-2348
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6433183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist