Provider Demographics
NPI:1841890910
Name:BENNETT, STEPHEN TRAVIS (PHARMD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:TRAVIS
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 1:11020 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-3002
Mailing Address - Country:US
Mailing Address - Phone:918-209-7016
Mailing Address - Fax:
Practice Address - Street 1:11020 S ELM ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-3002
Practice Address - Country:US
Practice Address - Phone:918-209-7016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18957183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist