Healthcare Provider Details

I. General information

NPI: 1104462829
Provider Name (Legal Business Name): BRET LYLE BENNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 S MALL DR
ST GEORGE UT
84790-1258
US

IV. Provider business mailing address

565 S MALL DR
ST GEORGE UT
84790-1258
US

V. Phone/Fax

Practice location:
  • Phone: 435-705-7420
  • Fax: 435-705-7421
Mailing address:
  • Phone: 435-705-7420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4821449-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: