Provider Demographics
NPI:1265715791
Name:BENNETT, NICHOLAS EDMOND (PHARMD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:EDMOND
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 N RILEY RD
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-1549
Mailing Address - Country:US
Mailing Address - Phone:623-570-1947
Mailing Address - Fax:
Practice Address - Street 1:8325 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-2125
Practice Address - Country:US
Practice Address - Phone:623-245-7353
Practice Address - Fax:623-245-7347
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018497183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist