Provider Demographics
NPI:1659693455
Name:BENJAMIN, ROBERT O
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:O
Last Name:BENJAMIN
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 1:616 LAKE BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75065-2887
Mailing Address - Country:US
Mailing Address - Phone:940-808-2706
Mailing Address - Fax:
Practice Address - Street 1:616 LAKE BRIDGE DR
Practice Address - Street 2:
Practice Address - City:LAKE DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75065-2887
Practice Address - Country:US
Practice Address - Phone:940-808-2706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY048050OtherNEW YORK STATE PHARMACIST'S LICENCE