Provider Demographics
NPI:1063001782
Name:BENNER, ZACKERY T (CPHT)
Entity Type:Individual
Prefix:
First Name:ZACKERY
Middle Name:T
Last Name:BENNER
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 MUSSER LN
Mailing Address - Street 2:
Mailing Address - City:MUNCY
Mailing Address - State:PA
Mailing Address - Zip Code:17756-5627
Mailing Address - Country:US
Mailing Address - Phone:570-428-5116
Mailing Address - Fax:
Practice Address - Street 1:801 N LOYALSOCK AVE
Practice Address - Street 2:
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754-1023
Practice Address - Country:US
Practice Address - Phone:570-368-5599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-16
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA30133157183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician