Basic Information
| Provider Information | |||||||||
| NPI: | 1962837922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODRUFF | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | KEVIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOODRUFF | ||||||||
| OtherFirstName: | BEN | ||||||||
| OtherMiddleName: | KEVIN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHARM D | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30225 W CHEERY LYNN RD | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853963173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238106720 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16380 W YUMA RD | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853383100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239254442 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2013 | ||||||||
| LastUpdateDate: | 09/10/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | S020141 | AZ | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.