Provider Demographics
NPI:1780402842
Name:BENNETT, RAVEN DANYELLE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:RAVEN
Middle Name:DANYELLE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:RAVEN
Other - Middle Name:DANYELLE
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2790 W CHERRY LN STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1102
Mailing Address - Country:US
Mailing Address - Phone:208-288-1496
Mailing Address - Fax:
Practice Address - Street 1:2790 W CHERRY LN STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1102
Practice Address - Country:US
Practice Address - Phone:208-288-1496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8561975183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist