Provider Demographics
NPI:1275576837
Name:BLACK, BENJAMIN ROLAND (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:ROLAND
Last Name:BLACK
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 1:3526 MOUNT VERNON ALSTON RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:GA
Mailing Address - Zip Code:30445-2301
Mailing Address - Country:US
Mailing Address - Phone:912-594-6061
Mailing Address - Fax:
Practice Address - Street 1:1704 MEADOWS LN
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8913
Practice Address - Country:US
Practice Address - Phone:912-537-4147
Practice Address - Fax:912-537-1914
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022024183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist