Provider Demographics
NPI:1548592520
Name:BENNETT, GARY J (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:J
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 1:687 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-3630
Mailing Address - Country:US
Mailing Address - Phone:212-246-8169
Mailing Address - Fax:212-265-7364
Practice Address - Street 1:687 9TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-3630
Practice Address - Country:US
Practice Address - Phone:212-246-8169
Practice Address - Fax:212-265-7364
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024724183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY024724OtherPHARMACIST LICENSE