Provider Demographics
NPI:1972279099
Name:LACROSS, BENJAMIN BRADLEY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:BRADLEY
Last Name:LACROSS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 KINGSTON CT APT C3
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-1481
Mailing Address - Country:US
Mailing Address - Phone:906-440-9569
Mailing Address - Fax:
Practice Address - Street 1:4900 M 72 E
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:MI
Practice Address - Zip Code:49690-9455
Practice Address - Country:US
Practice Address - Phone:231-534-9810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413716183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist