Provider Demographics
NPI:1366175291
Name:BENTON, PHILLIP PATRICK
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:PATRICK
Last Name:BENTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 SPILLWAY CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6035
Mailing Address - Country:US
Mailing Address - Phone:601-829-0743
Mailing Address - Fax:
Practice Address - Street 1:1070 SPILLWAY CIR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-6035
Practice Address - Country:US
Practice Address - Phone:601-829-0743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-100714183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist