Provider Demographics
NPI:1891079901
Name:JIMERSON, BENJAMIN JAY (RPH)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:JAY
Last Name:JIMERSON
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 1:11525 CANTERBERRY LN
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80138-8464
Mailing Address - Country:US
Mailing Address - Phone:720-214-1073
Mailing Address - Fax:720-214-1077
Practice Address - Street 1:13143 S PARKER RD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-3488
Practice Address - Country:US
Practice Address - Phone:720-214-1073
Practice Address - Fax:720-214-1077
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist