Provider Demographics
NPI:1790591253
Name:FERNANDEZ, BENITO
Entity type:Individual
Prefix:
First Name:BENITO
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23684 STRICKLAND DR
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20148-7726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23684 STRICKLAND DR
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20148-7726
Practice Address - Country:US
Practice Address - Phone:571-367-6039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202222031183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist