Provider Demographics
NPI:1265735518
Name:BENZER FL 5 LLC
Entity type:Organization
Organization Name:BENZER FL 5 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, AO
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-672-0600
Mailing Address - Street 1:500 W GRANADA BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-2304
Mailing Address - Country:US
Mailing Address - Phone:386-672-0600
Mailing Address - Fax:888-239-8423
Practice Address - Street 1:500 W GRANADA BLVD STE 4
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-2304
Practice Address - Country:US
Practice Address - Phone:386-672-0600
Practice Address - Fax:386-672-0700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH297313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016511500Medicaid
2156207OtherPK