Provider Demographics
NPI:1043317969
Name:BENZER CO 1 LLC
Entity type:Organization
Organization Name:BENZER CO 1 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:SIDDHARTH
Authorized Official - Middle Name:V
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:813-723-4111
Mailing Address - Street 1:568 US HWY 36
Mailing Address - Street 2:
Mailing Address - City:BYERS
Mailing Address - State:CO
Mailing Address - Zip Code:80103
Mailing Address - Country:US
Mailing Address - Phone:303-822-9371
Mailing Address - Fax:303-822-9746
Practice Address - Street 1:568 US HWY 36
Practice Address - Street 2:
Practice Address - City:BYERS
Practice Address - State:CO
Practice Address - Zip Code:80103
Practice Address - Country:US
Practice Address - Phone:303-822-9371
Practice Address - Fax:303-822-9746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPDO.1120000013336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000162035Medicaid
CO03165008Medicaid
0688760001Medicare NSC