Provider Demographics
NPI:1194586388
Name:BENNER, SELENA DESIREE (PHARMD, MPH, BSCR)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:DESIREE
Last Name:BENNER
Suffix:
Gender:F
Credentials:PHARMD, MPH, BSCR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5921 PRESWICKE LN
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-3176
Mailing Address - Country:US
Mailing Address - Phone:301-648-1996
Mailing Address - Fax:
Practice Address - Street 1:60 SHINING WILLOW WAY
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-4224
Practice Address - Country:US
Practice Address - Phone:301-934-5910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD29614183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist