Provider Demographics
NPI:1588183750
Name:BENNETT, KEITH ROBERT (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ROBERT
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 MANEWAL DR APT B
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4083
Mailing Address - Country:US
Mailing Address - Phone:908-202-7575
Mailing Address - Fax:908-202-7575
Practice Address - Street 1:5353 YELLOWSTONE RD RM 211
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4178
Practice Address - Country:US
Practice Address - Phone:888-385-0235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0021975183500000X
WY3983183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist