Provider Demographics
NPI:1871262196
Name:SPANN-BENTLEY, MIA
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:SPANN-BENTLEY
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 1:6419 INVERNESS WAY
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505-5409
Mailing Address - Country:US
Mailing Address - Phone:832-339-3110
Mailing Address - Fax:
Practice Address - Street 1:2955 GULF FWY S
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6750
Practice Address - Country:US
Practice Address - Phone:281-337-5142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX292294183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician