Provider Demographics
NPI:1710333299
Name:BALASKAS, BENJAMIN (RPH)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BALASKAS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5610 159TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-3104
Mailing Address - Country:US
Mailing Address - Phone:708-687-0122
Mailing Address - Fax:
Practice Address - Street 1:5610 159TH ST
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-3104
Practice Address - Country:US
Practice Address - Phone:708-687-0122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist