Provider Demographics
NPI:1922409796
Name:FOMINYAM, BENJAMIN F (PHARMD / MBA)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:F
Last Name:FOMINYAM
Suffix:
Gender:M
Credentials:PHARMD / MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16778 W APACHE ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-7433
Mailing Address - Country:US
Mailing Address - Phone:702-427-3000
Mailing Address - Fax:
Practice Address - Street 1:8325 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-2125
Practice Address - Country:US
Practice Address - Phone:623-245-7353
Practice Address - Fax:623-245-7347
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS020076183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist