Provider Demographics
NPI:1770964686
Name:DIBENEDETTO, LORI
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:DIBENEDETTO
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 1:1073 N VENTURA AVE
Mailing Address - Street 2:203
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-4700
Mailing Address - Country:US
Mailing Address - Phone:805-827-0879
Mailing Address - Fax:
Practice Address - Street 1:1073 N VENTURA AVE
Practice Address - Street 2:203
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001-4700
Practice Address - Country:US
Practice Address - Phone:805-827-0879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist