Healthcare Provider Details

I. General information

NPI: 1194177592
Provider Name (Legal Business Name): MARY THERESA BENNETT RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 W MAIN ST
FREMONT MI
49412-1419
US

IV. Provider business mailing address

10753 GARFIELD ST
COOPERSVILLE MI
49404-9741
US

V. Phone/Fax

Practice location:
  • Phone: 231-924-3790
  • Fax:
Mailing address:
  • Phone: 616-617-8643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302030215
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: