Provider Demographics
NPI:1710108360
Name:BENNETT, GORDON JR
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 LAWRENCE RD
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-4191
Mailing Address - Country:US
Mailing Address - Phone:603-432-5109
Mailing Address - Fax:
Practice Address - Street 1:20 CRYSTAL AVE
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-2412
Practice Address - Country:US
Practice Address - Phone:603-437-9799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1850183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist