Healthcare Provider Details

I. General information

NPI: 1477890978
Provider Name (Legal Business Name): BENJAMIN JOSEPH CLOUD PHARM D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2013
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 CIBCUE CIRCLE
SAN CARLOS AZ
85550-0208
US

IV. Provider business mailing address

PO BOX 208
SAN CARLOS AZ
85550-0208
US

V. Phone/Fax

Practice location:
  • Phone: 928-475-7269
  • Fax:
Mailing address:
  • Phone: 928-475-7269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number2011037526
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number2011037526
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: