Provider Demographics
NPI:1831433234
Name:BEN, MARK THEODORE (PHARM D)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THEODORE
Last Name:BEN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 E BASTANCHURY RD
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-2786
Mailing Address - Country:US
Mailing Address - Phone:714-674-0900
Mailing Address - Fax:
Practice Address - Street 1:1040 E BASTANCHURY RD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2786
Practice Address - Country:US
Practice Address - Phone:714-674-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 38950183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist