Provider Demographics
NPI:1851317820
Name:BENNETT, STACEY ANN (RPH)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:ANN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:ANN
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:4449 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009
Mailing Address - Country:US
Mailing Address - Phone:269-806-0421
Mailing Address - Fax:269-624-5704
Practice Address - Street 1:350 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:MI
Practice Address - Zip Code:49065-9249
Practice Address - Country:US
Practice Address - Phone:269-624-2231
Practice Address - Fax:269-624-5704
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist