Provider Demographics
NPI:1417365396
Name:GANDOLFI, BENJAMIN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:GANDOLFI
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 1:4501 AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-5646
Mailing Address - Country:US
Mailing Address - Phone:504-885-4867
Mailing Address - Fax:
Practice Address - Street 1:4501 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-5646
Practice Address - Country:US
Practice Address - Phone:504-885-4867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020653183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist