Provider Demographics
NPI:1356627301
Name:JAQUES, BENJAMIN EUGENE (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:EUGENE
Last Name:JAQUES
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18040 SW LOWER BOONES FERRY RD STE 104
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7259
Mailing Address - Country:US
Mailing Address - Phone:503-216-0626
Mailing Address - Fax:503-216-0630
Practice Address - Street 1:18040 SW LOWER BOONES FERRY RD STE 104
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7259
Practice Address - Country:US
Practice Address - Phone:503-216-0626
Practice Address - Fax:503-216-0630
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0012721183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist