Provider Demographics
NPI:1942510797
Name:BENAVIDES, HAZEL ANNE PERILLA
Entity Type:Individual
Prefix:MRS
First Name:HAZEL ANNE
Middle Name:PERILLA
Last Name:BENAVIDES
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:HAZEL ANNE
Other - Middle Name:SANIDAD
Other - Last Name:PERILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8215 JADE COAST RD.
Mailing Address - Street 2:UNIT # 84
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-6462
Mailing Address - Country:US
Mailing Address - Phone:858-610-5967
Mailing Address - Fax:
Practice Address - Street 1:8215 JADE COAST RD.
Practice Address - Street 2:UNIT # 84
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-6462
Practice Address - Country:US
Practice Address - Phone:858-610-5967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74261183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician