Provider Demographics
NPI:1114282639
Name:SELPH, BENJAMIN MICHAEL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:MICHAEL
Last Name:SELPH
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 1:15104 TIPPETTVILLE RD
Mailing Address - Street 2:
Mailing Address - City:PINEVIEW
Mailing Address - State:GA
Mailing Address - Zip Code:31071-3019
Mailing Address - Country:US
Mailing Address - Phone:229-624-2894
Mailing Address - Fax:
Practice Address - Street 1:1826 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-3620
Practice Address - Country:US
Practice Address - Phone:478-272-1210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH026683183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH026683OtherPHARMACIST LICENSE