Provider Demographics
NPI:1558772434
Name:BENTLEY, OLIVIA SANTOSO (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:OLIVIA
Middle Name:SANTOSO
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:OLIVIA
Other - Middle Name:REGINA
Other - Last Name:SANTOSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:7308 E INDEPENDENCE BLVD STE I
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-9440
Mailing Address - Country:US
Mailing Address - Phone:704-537-0909
Mailing Address - Fax:704-537-0947
Practice Address - Street 1:7308 E INDEPENDENCE BLVD STE I
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-9440
Practice Address - Country:US
Practice Address - Phone:704-537-0909
Practice Address - Fax:704-537-0947
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2015-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22881183500000X
GA026916183500000X
1722225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter