Provider Demographics
NPI:1043337652
Name:BENEDICT, ROBERT WILSON (RPH)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WILSON
Last Name:BENEDICT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11732 SYLVESTER DR
Mailing Address - Street 2:
Mailing Address - City:ELSAH
Mailing Address - State:IL
Mailing Address - Zip Code:62028-7020
Mailing Address - Country:US
Mailing Address - Phone:618-374-2154
Mailing Address - Fax:
Practice Address - Street 1:9521 LEWIS & CLARK BLVD
Practice Address - Street 2:
Practice Address - City:MOLINE ACRES
Practice Address - State:MO
Practice Address - Zip Code:63136
Practice Address - Country:US
Practice Address - Phone:618-869-2897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO045307183500000X
IL051-290176183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist