Provider Demographics
NPI:1881291037
Name:LACKNER, BENJAMIN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:LACKNER
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 1:1267 ARROWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15243-1857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:68501 ADDIE WAY
Practice Address - Street 2:
Practice Address - City:SAINT CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950-9537
Practice Address - Country:US
Practice Address - Phone:740-695-6322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP454093183500000X
OH03439298183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist