Healthcare Provider Details

I. General information

NPI: 1659837169
Provider Name (Legal Business Name): BENJAMIN MICHAEL KHLEVNOY RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 N TRIPHAMMER RD
ITHACA NY
14850-1576
US

IV. Provider business mailing address

2255 N TRIPHAMMER RD
ITHACA NY
14850-1576
US

V. Phone/Fax

Practice location:
  • Phone: 607-330-5692
  • Fax: 607-257-0449
Mailing address:
  • Phone: 607-330-5692
  • Fax: 607-257-0449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number064335
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: