Healthcare Provider Details

I. General information

NPI: 1235272998
Provider Name (Legal Business Name): CLYDE BENNETT RPH, CDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

566 S 8TH ST
GRIFFIN GA
30224-4212
US

IV. Provider business mailing address

566 S 8TH ST
GRIFFIN GA
30224-4212
US

V. Phone/Fax

Practice location:
  • Phone: 770-467-6500
  • Fax: 770-467-6513
Mailing address:
  • Phone: 770-467-6500
  • Fax: 770-467-6513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8319
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: