Provider Demographics
NPI:1811520489
Name:BENSON, RUSSLE CALVINIST (PHARMD)
Entity type:Individual
Prefix:DR
First Name:RUSSLE
Middle Name:CALVINIST
Last Name:BENSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12168 YOUNGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-5261
Mailing Address - Country:US
Mailing Address - Phone:818-748-5508
Mailing Address - Fax:
Practice Address - Street 1:1800 N PERRIS BLVD
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2701
Practice Address - Country:US
Practice Address - Phone:951-940-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81676183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist