Provider Demographics
NPI:1295923647
Name:BENTON, ERICA S
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:S
Last Name:BENTON
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 1:5845 PENNEY LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-3827
Mailing Address - Country:US
Mailing Address - Phone:904-779-9867
Mailing Address - Fax:
Practice Address - Street 1:4645 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-7324
Practice Address - Country:US
Practice Address - Phone:904-771-5432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS31009183500000X
FLPU5110183500000X
VA0202011519183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist