Provider Demographics
NPI:1538883848
Name:KOMISTRA, BENJAMIN WILLIAM (PHARMD, RPH)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:WILLIAM
Last Name:KOMISTRA
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4924 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-3349
Mailing Address - Country:US
Mailing Address - Phone:262-997-9573
Mailing Address - Fax:262-997-9574
Practice Address - Street 1:4924 7TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-3349
Practice Address - Country:US
Practice Address - Phone:262-997-9573
Practice Address - Fax:262-997-9574
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19339-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist