Provider Demographics
NPI:1346797818
Name:DOUGHTY, BENNETT JACKSON (PHARMD, BCPS, BCPP)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:JACKSON
Last Name:DOUGHTY
Suffix:
Gender:M
Credentials:PHARMD, BCPS, BCPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6000
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13902-6000
Mailing Address - Country:US
Mailing Address - Phone:207-313-9268
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0013678183500000X
PARP4524721835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric
No183500000XPharmacy Service ProvidersPharmacist