Provider Demographics
NPI:1760013429
Name:DE VAULL-BENSON, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:DE VAULL-BENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27378 ROSEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-4000
Mailing Address - Country:US
Mailing Address - Phone:313-802-2458
Mailing Address - Fax:
Practice Address - Street 1:31505 JOY RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1641
Practice Address - Country:US
Practice Address - Phone:734-427-9102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027433183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist