Healthcare Provider Details

I. General information

NPI: 1821173055
Provider Name (Legal Business Name): JERRY BENNETT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 MAIN STREET
MOUNTAIN VIEW OK
73062-0720
US

IV. Provider business mailing address

PO BOX 140
MOUNTAIN VIEW OK
73062-0140
US

V. Phone/Fax

Practice location:
  • Phone: 580-347-2519
  • Fax: 580-347-2319
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number413679
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JERRY BENNETT
Title or Position: OWNER
Credential:
Phone: 580-347-2519