1255324836 NPI number — BEN-RAY INC.

Table of content: (NPI 1255324836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255324836 NPI number — BEN-RAY INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEN-RAY INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EVANS PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255324836
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4474
Provider Second Line Business Mailing Address:
310 N. DOTSY AVE
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79760-4474
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-337-2361
Provider Business Mailing Address Fax Number:
432-337-0310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 DOTSY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79763-4342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-337-2361
Provider Business Practice Location Address Fax Number:
432-337-0310
Provider Enumeration Date:
08/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HAWLEY
Authorized Official First Name:
BENTLEY
Authorized Official Middle Name:
FRED
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
432-337-2361

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  01918 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 140119 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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