Provider Demographics
NPI:1437433901
Name:DALE, BENJAMIN WAYNE
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:WAYNE
Last Name:DALE
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 1:2009 W 120TH ST S
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-2990
Mailing Address - Country:US
Mailing Address - Phone:918-298-4072
Mailing Address - Fax:
Practice Address - Street 1:11 W TAFT AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-5430
Practice Address - Country:US
Practice Address - Phone:918-227-0878
Practice Address - Fax:918-227-1193
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13067183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100245420AMedicaid