Provider Demographics
NPI:1497272843
Name:CIVIN, HARRISON BENJAMIN (RPH)
Entity Type:Individual
Prefix:DR
First Name:HARRISON
Middle Name:BENJAMIN
Last Name:CIVIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4234 FOXWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:81 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GOWANDA
Practice Address - State:NY
Practice Address - Zip Code:14070-1318
Practice Address - Country:US
Practice Address - Phone:716-532-4114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-26
Last Update Date:2017-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI063255183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist