Healthcare Provider Details

I. General information

NPI: 1205728755
Provider Name (Legal Business Name): DIEGO BENAVIDES PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2025
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 22ND AVE
MONROE WI
53566-1569
US

IV. Provider business mailing address

515 22ND AVE
MONROE WI
53566-1569
US

V. Phone/Fax

Practice location:
  • Phone: 608-324-2259
  • Fax:
Mailing address:
  • Phone: 704-657-1566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number23090-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: