Provider Demographics
NPI:1093280539
Name:BENNETTS HOMETOWN PHARMACY- BLACKSHEAR LLC
Entity Type:Organization
Organization Name:BENNETTS HOMETOWN PHARMACY- BLACKSHEAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,PHARMACIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-286-3784
Mailing Address - Street 1:PO BOX 864
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-0864
Mailing Address - Country:US
Mailing Address - Phone:912-286-3784
Mailing Address - Fax:
Practice Address - Street 1:3150 US HIGHWAY 84
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516-4944
Practice Address - Country:US
Practice Address - Phone:912-449-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA391060474AMedicaid