Provider Demographics
NPI:1730464728
Name:BENSON, BRYAN M
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:M
Last Name:BENSON
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 1:3050 A NUTLEY ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3050 A NUTLEY ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031
Practice Address - Country:US
Practice Address - Phone:703-280-8259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202210201183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist