Provider Demographics
NPI:1447436142
Name:BENTON, MECHELE L
Entity type:Individual
Prefix:
First Name:MECHELE
Middle Name:L
Last Name:BENTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:AVOCA
Mailing Address - State:NY
Mailing Address - Zip Code:14809-0071
Mailing Address - Country:US
Mailing Address - Phone:607-566-2231
Mailing Address - Fax:
Practice Address - Street 1:338 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-1024
Practice Address - Country:US
Practice Address - Phone:607-776-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0351521183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist