Provider Demographics
NPI:1902223944
Name:BENZIE, KRISTINE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:BENZIE
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 1:30186 690TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:MN
Mailing Address - Zip Code:56673-3416
Mailing Address - Country:US
Mailing Address - Phone:218-463-2420
Mailing Address - Fax:218-463-2421
Practice Address - Street 1:1087 3RD ST NW
Practice Address - Street 2:
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751-1902
Practice Address - Country:US
Practice Address - Phone:218-463-2420
Practice Address - Fax:218-463-2421
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116318183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist