Provider Demographics
NPI:1417052937
Name:DOUGLAS EARL BENNETT
Entity Type:Organization
Organization Name:DOUGLAS EARL BENNETT
Other - Org Name:EL DORADO DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER-PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:209-464-7722
Mailing Address - Street 1:2005 S MARIPOSA RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-7735
Mailing Address - Country:US
Mailing Address - Phone:209-464-7722
Mailing Address - Fax:209-464-7404
Practice Address - Street 1:2005 S MARIPOSA RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-7735
Practice Address - Country:US
Practice Address - Phone:209-464-7722
Practice Address - Fax:209-464-7404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY1876003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0510239OtherNABP
CAPHA187600Medicaid
4487770001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER