Provider Demographics
NPI:1588950604
Name:DEJESUS, BENJAMIN JR
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:
Last Name:DEJESUS
Suffix:JR
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 1:11311 BANDERA RD
Mailing Address - Street 2:TARGET PHARMACY
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78250-6812
Mailing Address - Country:US
Mailing Address - Phone:210-682-2533
Mailing Address - Fax:210-682-2533
Practice Address - Street 1:11311 BANDERA RD
Practice Address - Street 2:TARGET PHARMACY
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78250-6812
Practice Address - Country:US
Practice Address - Phone:210-682-2533
Practice Address - Fax:210-682-2533
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21182183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist