Provider Demographics
NPI:1003959222
Name:BENNETT, TRACEY LYNN (RPH)
Entity type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:LYNN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 337TH ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:IA
Mailing Address - Zip Code:50220-8500
Mailing Address - Country:US
Mailing Address - Phone:515-436-7212
Mailing Address - Fax:515-465-9467
Practice Address - Street 1:1215 141ST ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:IA
Practice Address - Zip Code:50220-8127
Practice Address - Country:US
Practice Address - Phone:515-465-3543
Practice Address - Fax:515-465-9467
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17947183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist