Provider Demographics
NPI:1316193188
Name:BENNETT, THOMAS R (RPH)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:R
Last Name:BENNETT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CRUTCHER ST
Mailing Address - Street 2:
Mailing Address - City:VINE GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:40175-1409
Mailing Address - Country:US
Mailing Address - Phone:270-877-5111
Mailing Address - Fax:270-877-6232
Practice Address - Street 1:107 CRUTCHER ST
Practice Address - Street 2:
Practice Address - City:VINE GROVE
Practice Address - State:KY
Practice Address - Zip Code:40175-1409
Practice Address - Country:US
Practice Address - Phone:270-877-5111
Practice Address - Fax:270-877-6232
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8278183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist