Provider Demographics
NPI:1699814129
Name:DIRUSSO, BENEDICT JOSEPH JR (RPH, MBA)
Entity Type:Individual
Prefix:MR
First Name:BENEDICT
Middle Name:JOSEPH
Last Name:DIRUSSO
Suffix:JR
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 DANBY RD
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3004
Mailing Address - Country:US
Mailing Address - Phone:781-279-0788
Mailing Address - Fax:
Practice Address - Street 1:75 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4960
Practice Address - Country:US
Practice Address - Phone:617-496-6664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18312183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist