Provider Demographics
NPI:1932441110
Name:BENTON, DERRICK M (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:M
Last Name:BENTON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36601 EAST LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684
Mailing Address - Country:US
Mailing Address - Phone:727-785-8837
Mailing Address - Fax:727-786-1547
Practice Address - Street 1:36301 EAST LAKE RD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684
Practice Address - Country:US
Practice Address - Phone:727-785-8837
Practice Address - Fax:727-786-1547
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS47603183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist