Provider Demographics
NPI:1750668364
Name:BENCIVENGA, GINA ANN (PHARMD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:ANN
Last Name:BENCIVENGA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 FORTUNE BLVD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-1743
Mailing Address - Country:US
Mailing Address - Phone:508-478-5267
Mailing Address - Fax:
Practice Address - Street 1:250 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-1743
Practice Address - Country:US
Practice Address - Phone:508-478-5267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH25718183500000X
RIRPH05075183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI4106438Medicare Oscar/Certification
MA2238334Medicare Oscar/Certification