Provider Demographics
NPI:1932483682
Name:BENINGO, AMY LYNNE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LYNNE
Last Name:BENINGO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 W MAIN ST
Mailing Address - Street 2:PO BOX 399
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1998
Mailing Address - Country:US
Mailing Address - Phone:989-732-4114
Mailing Address - Fax:989-731-3212
Practice Address - Street 1:829 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1998
Practice Address - Country:US
Practice Address - Phone:989-732-4114
Practice Address - Fax:989-731-3212
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028374183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302028374OtherPHARMACIST STATE LISCENCE