Provider Demographics
NPI:1851673842
Name:BENNETT, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BENNETT
Suffix:
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 1:917 W SAVIDGE ST
Mailing Address - Street 2:UNIT 34
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2624
Mailing Address - Country:US
Mailing Address - Phone:616-847-8520
Mailing Address - Fax:
Practice Address - Street 1:3610 PLAINFIELD AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-2402
Practice Address - Country:US
Practice Address - Phone:616-365-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021378183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist