Provider Demographics
NPI:1962492314
Name:BENNETT, RAYMOND M JR (BS PHARM)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:M
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:BS PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5937 N MERRIMAC AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5326
Mailing Address - Country:US
Mailing Address - Phone:773-631-2085
Mailing Address - Fax:
Practice Address - Street 1:5230 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-4624
Practice Address - Country:US
Practice Address - Phone:773-736-8920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2011-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051032325183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist