Provider Demographics
NPI:1235477753
Name:POWELL, BENJAMIN (RPH)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:POWELL
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 1:2075 S HAIRSTON RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-2504
Mailing Address - Country:US
Mailing Address - Phone:770-322-6557
Mailing Address - Fax:770-322-8775
Practice Address - Street 1:2075 S HAIRSTON RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-2504
Practice Address - Country:US
Practice Address - Phone:770-322-6557
Practice Address - Fax:770-322-8775
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023446183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist