Healthcare Provider Details

I. General information

NPI: 1639133689
Provider Name (Legal Business Name): BENNET SAMPAYAN BLANCAFLOR PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3481 BOB WILSON DRIVE
SAN DIEGO CA
92134-1113
US

IV. Provider business mailing address

6241 CALLE MARISELDA
SAN DIEGO CA
92124-1170
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-8401
  • Fax:
Mailing address:
  • Phone: 858-505-9401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number44418
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number1535
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: