Provider Demographics
NPI:1235272998
Name:BENNETT, CLYDE (RPH, CDE)
Entity Type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:RPH, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:566 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4212
Mailing Address - Country:US
Mailing Address - Phone:770-467-6500
Mailing Address - Fax:770-467-6513
Practice Address - Street 1:566 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4212
Practice Address - Country:US
Practice Address - Phone:770-467-6500
Practice Address - Fax:770-467-6513
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8319183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist