Provider Demographics
NPI:1366724627
Name:BENJAMIN, MICHAEL A (REG PHARMACIST)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:REG PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 POWDER HILL RD
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01740-1083
Mailing Address - Country:US
Mailing Address - Phone:978-466-1221
Mailing Address - Fax:
Practice Address - Street 1:11 JUNGLE RD
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-5207
Practice Address - Country:US
Practice Address - Phone:978-466-1221
Practice Address - Fax:978-466-8027
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10193183500000X
MAPH26635183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist