Provider Demographics
NPI:1679295323
Name:STREET, BENJAMIN ETHAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ETHAN
Last Name:STREET
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 LAGRANGE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24630-8432
Mailing Address - Country:US
Mailing Address - Phone:276-385-3665
Mailing Address - Fax:
Practice Address - Street 1:155 W LEE HWY
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE,
Practice Address - State:VA
Practice Address - Zip Code:24382
Practice Address - Country:US
Practice Address - Phone:276-239-6132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202220704183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist