Provider Demographics
NPI:1699095240
Name:DIBENEDETTO, THOMAS (RPH)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:DIBENEDETTO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 ROBINSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4209
Mailing Address - Country:US
Mailing Address - Phone:619-291-3705
Mailing Address - Fax:
Practice Address - Street 1:535 ROBINSON AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4209
Practice Address - Country:US
Practice Address - Phone:619-291-3705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-06
Last Update Date:2010-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46169183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist