Healthcare Provider Details

I. General information

NPI: 1447416193
Provider Name (Legal Business Name): BENJAMIN JACOB DEMONGEY PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 SIXTH ST
TRAVERSE CITY MI
49684-2345
US

IV. Provider business mailing address

3883 CENTRAL PARK DR
GRAWN MI
49637-9721
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-6598
  • Fax:
Mailing address:
  • Phone: 231-409-0168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835N1003X
TaxonomyNutrition Support Pharmacist
License Number5302033882
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: