Provider Demographics
NPI:1518403724
Name:BENNETT, MARK ANDREW (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANDREW
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S COMMERCE WAY
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3117
Mailing Address - Country:US
Mailing Address - Phone:435-734-9784
Mailing Address - Fax:
Practice Address - Street 1:1200 S COMMERCE WAY
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3117
Practice Address - Country:US
Practice Address - Phone:435-734-9784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8658054-1701183500000X
UT8658054-8911183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist