Provider Demographics
NPI:1689369316
Name:BENDER, LYDIA
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:BENDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17167 DUNE VIEW DR APT 210
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-7926
Mailing Address - Country:US
Mailing Address - Phone:760-814-7376
Mailing Address - Fax:
Practice Address - Street 1:603 E SAVIDGE ST
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-1956
Practice Address - Country:US
Practice Address - Phone:616-842-1461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303043856183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician