MEDICARE: KETTLY BENJAMIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	0447951	NY

General Provider Information

NPI Number	:	1558684837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KETTLY BENJAMIN

Provider Business Mailing Address
First Line	:	1404 ROCKAWAY PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-2322
Country	:	US
Telephone Number	:	718-257-2916
Fax Number	:	718-257-1720

Provider Business Practice Location Address
First Line	:	1404 ROCKAWAY PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-2322
Country	:	US
Telephone Number	:	718-257-2916
Fax Number	:	718-257-1720

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2010
Last Update Date	:	03/01/2010

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Directions to “ KETTLY BENJAMIN ” Practice Location

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