Healthcare Provider Details

I. General information

NPI: 1841282472
Provider Name (Legal Business Name): RAE LYNN BENTON RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 NORTHSIDE FORSYTH DR NORTHSIDE HOSPITAL FORSYTH PHARMACY
CUMMING GA
30041-7659
US

IV. Provider business mailing address

120 RIVERCREST LN
SUWANEE GA
30024-5439
US

V. Phone/Fax

Practice location:
  • Phone: 770-844-3291
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH014641
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: