=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053686444
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES BRUCE BENTON RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2012
-----------------------------------------------------
Last Update Date | 03/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26191 JOHN WILLIAMS HWY
-----------------------------------------------------
City | MILLSBORO
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-945-6064
-----------------------------------------------------
Fax | 302-945-5999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34923 VESSEL CV
-----------------------------------------------------
City | LEWES
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19958-2748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-645-8202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | A1-0001828
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------