MEDICARE: JEFFREY RYAN BENNETT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0510239	OTHER		NCPDP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	PHY59418	OTHER	CA	CALIFORNIA STATE BOARD OF PHARMACY

General Provider Information

NPI Number	:	1417052937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFFREY RYAN BENNETT

Provider Business Mailing Address
First Line	:	2005 S MARIPOSA RD
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95205-7735
Country	:	US
Telephone Number	:	209-464-7722
Fax Number	:	209-464-7404

Provider Business Practice Location Address
First Line	:	2005 S MARIPOSA RD
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95205-7735
Country	:	US
Telephone Number	:	209-464-7722
Fax Number	:	209-464-7404

Authorized Official
Title or Position	:	OWNER
Name	:	JEFFREY BENNETT
Credential	:
Telephone Number	:	209-464-7722

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	09/16/2025

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