Provider Demographics
NPI:1083860084
Name:BENJAMIN ROTHMAN A PHARMACY CORPORATION
Entity Type:Organization
Organization Name:BENJAMIN ROTHMAN A PHARMACY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-992-1234
Mailing Address - Street 1:100 E VALENCIA MESA DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3813
Mailing Address - Country:US
Mailing Address - Phone:714-992-1234
Mailing Address - Fax:714-992-6668
Practice Address - Street 1:100 E VALENCIA MESA DR
Practice Address - Street 2:SUITE 106
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3813
Practice Address - Country:US
Practice Address - Phone:714-992-1234
Practice Address - Fax:714-992-6668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-11
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA485963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0602430001Medicare NSC