Provider Demographics
NPI:1265029342
Name:BENNETT, STETSON FLEMING III
Entity Type:Individual
Prefix:
First Name:STETSON
Middle Name:FLEMING
Last Name:BENNETT
Suffix:III
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 1:700 ONEAL RD
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31546-2680
Mailing Address - Country:US
Mailing Address - Phone:912-387-6856
Mailing Address - Fax:
Practice Address - Street 1:731 CAMERON DR
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516-1309
Practice Address - Country:US
Practice Address - Phone:912-449-4444
Practice Address - Fax:912-449-8735
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH018690183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist