Provider Demographics
NPI:1609401439
Name:HUTTO, BENJAMIN ROBERT
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ROBERT
Last Name:HUTTO
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 1:36TH MEDICAL GROUP
Mailing Address - Street 2:UNIT 14010 BLDG 2600 CAROLINES
Mailing Address - City:YIGO
Mailing Address - State:GU
Mailing Address - Zip Code:96929
Mailing Address - Country:US
Mailing Address - Phone:671-688-3419
Mailing Address - Fax:
Practice Address - Street 1:1234A PALAU LP
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96929
Practice Address - Country:US
Practice Address - Phone:671-688-3419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-12
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67338183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist