Provider Demographics
NPI:1003417601
Name:CAPPS, BENNETT PORTER
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:PORTER
Last Name:CAPPS
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 1:406 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:STUTTGART
Mailing Address - State:AR
Mailing Address - Zip Code:72160-9006
Mailing Address - Country:US
Mailing Address - Phone:870-673-1834
Mailing Address - Fax:
Practice Address - Street 1:406 E 22ND ST
Practice Address - Street 2:
Practice Address - City:STUTTGART
Practice Address - State:AR
Practice Address - Zip Code:72160-9006
Practice Address - Country:US
Practice Address - Phone:870-673-1834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD11061183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist