Provider Demographics
NPI:1053455824
Name:ILONZO, BENNETH (RPH)
Entity type:Individual
Prefix:MR
First Name:BENNETH
Middle Name:
Last Name:ILONZO
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 1:617 DEER MOSS CT
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-1108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:345 HAVENDALE BLVD
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-4513
Practice Address - Country:US
Practice Address - Phone:863-967-7803
Practice Address - Fax:863-967-8696
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0022868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106552100Medicaid
FL106552100Medicaid