MEDICARE: JACK BENNETT JR.

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	183500000X	Pharmacist	29861	TX

General Provider Information

NPI Number	:	1972831352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK BENNETT JR.

Provider Business Mailing Address
First Line	:	1307 FM 1092 RD
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-1504
Country	:	US
Telephone Number	:	281-499-5150
Fax Number	:	281-261-3082

Provider Business Practice Location Address
First Line	:	1307 FM 1092 RD
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-1504
Country	:	US
Telephone Number	:	281-499-5150
Fax Number	:	281-261-3082

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/24/2009
Last Update Date	:	11/24/2009

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Directions to “ JACK BENNETT JR. ” Practice Location

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