Provider Demographics
NPI:1952954885
Name:PROCTOR, BENJAMIN ALEX (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:ALEX
Last Name:PROCTOR
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 1:7733 W 55TH AVE APT 306
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80002-4510
Mailing Address - Country:US
Mailing Address - Phone:720-394-1169
Mailing Address - Fax:
Practice Address - Street 1:1535 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-5993
Practice Address - Country:US
Practice Address - Phone:970-674-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22728183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22728OtherPHARMACIST LICENSE