Provider Demographics
NPI:1164792503
Name:STRAIN, BENTON COILEY (RPH)
Entity Type:Individual
Prefix:
First Name:BENTON
Middle Name:COILEY
Last Name:STRAIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:BENTON
Other - Middle Name:COILEY
Other - Last Name:STRAIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:107 ST REGIS DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7939
Mailing Address - Country:US
Mailing Address - Phone:601-270-8536
Mailing Address - Fax:601-926-1234
Practice Address - Street 1:204 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4716
Practice Address - Country:US
Practice Address - Phone:601-926-1179
Practice Address - Fax:601-926-1234
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-05971183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist