Provider Demographics
NPI:1083639017
Name:BENNETT, JOHN (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:CARL
Other - Middle Name:JOHNSON
Other - Last Name:BENNETT
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:106 LINVILLE
Mailing Address - Street 2:P.O. BOX 836
Mailing Address - City:GLEN ALPINE
Mailing Address - State:NC
Mailing Address - Zip Code:28628-0836
Mailing Address - Country:US
Mailing Address - Phone:828-584-0741
Mailing Address - Fax:828-584-0744
Practice Address - Street 1:106 LINVILLE
Practice Address - Street 2:
Practice Address - City:GLEN ALPINE
Practice Address - State:NC
Practice Address - Zip Code:28628-0836
Practice Address - Country:US
Practice Address - Phone:828-584-0741
Practice Address - Fax:828-584-0744
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6765183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0125450Medicaid
NC3406508Medicare UPIN
NC0125450Medicaid