Provider Demographics
NPI:1114513397
Name:LEE, BENJAMIN (RPH)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 STAGECOACH TRL
Mailing Address - Street 2:
Mailing Address - City:WIMAUMA
Mailing Address - State:FL
Mailing Address - Zip Code:33598-7526
Mailing Address - Country:US
Mailing Address - Phone:313-580-2547
Mailing Address - Fax:
Practice Address - Street 1:10623 GIBSONTON DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-5404
Practice Address - Country:US
Practice Address - Phone:813-677-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-12
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS40938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist