Provider Demographics
NPI:1144622473
Name:BENTLEY, DONOVAN
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11349 STATE HIGHWAY1056
Mailing Address - Street 2:BUSKIRK PLAZA
Mailing Address - City:MCCARR
Mailing Address - State:KY
Mailing Address - Zip Code:41544
Mailing Address - Country:US
Mailing Address - Phone:606-427-9007
Mailing Address - Fax:606-427-9184
Practice Address - Street 1:11349 STATE HIGHWAY1056
Practice Address - Street 2:BUSKIRK PLAZA
Practice Address - City:MCCARR
Practice Address - State:KY
Practice Address - Zip Code:41544
Practice Address - Country:US
Practice Address - Phone:606-427-9007
Practice Address - Fax:606-427-9184
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY017216183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist