Healthcare Provider Details

I. General information

NPI: 1316193188
Provider Name (Legal Business Name): THOMAS R. BENNETT R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 CRUTCHER ST
VINE GROVE KY
40175-1409
US

IV. Provider business mailing address

107 CRUTCHER ST
VINE GROVE KY
40175-1409
US

V. Phone/Fax

Practice location:
  • Phone: 270-877-5111
  • Fax: 270-877-6232
Mailing address:
  • Phone: 270-877-5111
  • Fax: 270-877-6232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8278
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: