Provider Demographics
NPI:1134210016
Name:BENTLEY, MECHELLE LYNNETTE
Entity type:Individual
Prefix:
First Name:MECHELLE
Middle Name:LYNNETTE
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MECHELLE
Other - Middle Name:LYNNETTE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:212 NORTH ASH
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601
Mailing Address - Country:US
Mailing Address - Phone:580-716-6671
Mailing Address - Fax:580-765-0668
Practice Address - Street 1:301 WEST GRAND
Practice Address - Street 2:TONIS WESTSIDE PHARMACY
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601
Practice Address - Country:US
Practice Address - Phone:580-765-4456
Practice Address - Fax:580-765-0668
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKT4102183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0237820001Medicare ID - Type Unspecified