Provider Demographics
NPI:1205642592
Name:BENNETT, JEFFREY RYAN
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RYAN
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 1:2005 S MARIPOSA RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205
Mailing Address - Country:US
Mailing Address - Phone:209-464-7722
Mailing Address - Fax:
Practice Address - Street 1:2005 S MARIPOSA RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205
Practice Address - Country:US
Practice Address - Phone:209-464-7722
Practice Address - Fax:209-464-3780
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY594183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0510239OtherNATIONAL COUNCIL FOR PRESCRIPTION DRUG PROGRAMS
CAPHY59418OtherCALIFORNIA STATE BOARD OF PHARMACY