Provider Demographics
NPI:1114149507
Name:BENSON, BOBBY
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:BENSON
Suffix:
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 1:6235 IGINLAS GOAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131
Mailing Address - Country:US
Mailing Address - Phone:702-528-5336
Mailing Address - Fax:702-642-5102
Practice Address - Street 1:2671 LAS VEGAS BLVD NORTH
Practice Address - Street 2:
Practice Address - City:N. LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030
Practice Address - Country:US
Practice Address - Phone:702-649-3529
Practice Address - Fax:702-642-5102
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13553183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2902080Medicaid