Provider Demographics
NPI:1952812471
Name:WATKINS, BENJAMIN RUSSELL (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:RUSSELL
Last Name:WATKINS
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9700 E 108TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-7238
Mailing Address - Country:US
Mailing Address - Phone:918-527-2396
Mailing Address - Fax:
Practice Address - Street 1:100 N J M DAVIS BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-6811
Practice Address - Country:US
Practice Address - Phone:918-341-4938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15328183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist