Provider Demographics
NPI:1992478432
Name:GUSTAFSON, BENJAMIN (PHARMD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:GUSTAFSON
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 1:3345 GLADE CREEK BLVD NE APT 12
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-8620
Mailing Address - Country:US
Mailing Address - Phone:715-409-0437
Mailing Address - Fax:
Practice Address - Street 1:1906 BELLEVIEW AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1838
Practice Address - Country:US
Practice Address - Phone:540-981-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30488183500000X
VA0202219693183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist