Provider Demographics
NPI:1558642009
Name:BENNETT, KIM L (DPH)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 TRAILHEAD DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-0830
Mailing Address - Country:US
Mailing Address - Phone:058-234-7904
Mailing Address - Fax:
Practice Address - Street 1:1621 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-5020
Practice Address - Country:US
Practice Address - Phone:405-260-1574
Practice Address - Fax:405-260-1643
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist