Provider Demographics
NPI:1558499160
Name:BENN, MATTHEW BRYAN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRYAN
Last Name:BENN
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 1:276 SUN RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-6505
Mailing Address - Country:US
Mailing Address - Phone:831-476-4806
Mailing Address - Fax:
Practice Address - Street 1:201 FRONT ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4544
Practice Address - Country:US
Practice Address - Phone:831-421-9142
Practice Address - Fax:831-421-9392
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70170183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist