Provider Demographics
NPI:1568703981
Name:BENITO, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BENITO
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 1:13122 BLANCHE COKER ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2321
Mailing Address - Country:US
Mailing Address - Phone:210-393-9087
Mailing Address - Fax:
Practice Address - Street 1:6520 FRATT RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218-4402
Practice Address - Country:US
Practice Address - Phone:210-938-4536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24711183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist