Provider Demographics
NPI:1215693361
Name:DOROUGH, BENJAMIN JOEL
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOEL
Last Name:DOROUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12072 ARBOR LAKE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-3681
Mailing Address - Country:US
Mailing Address - Phone:904-608-8928
Mailing Address - Fax:
Practice Address - Street 1:12072 ARBOR LAKE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-3681
Practice Address - Country:US
Practice Address - Phone:904-608-8928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52929183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist