Provider Demographics
NPI:1396358180
Name:MUOGHALU, BENJAMIN C
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:C
Last Name:MUOGHALU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-4328
Mailing Address - Country:US
Mailing Address - Phone:630-854-2067
Mailing Address - Fax:
Practice Address - Street 1:200 WILMOT RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4620
Practice Address - Country:US
Practice Address - Phone:847-315-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019047126183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist