=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598760761
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENT;LEY PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2005
-----------------------------------------------------
Last Update Date | 12/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 W MOORE AVE
-----------------------------------------------------
City | TERRELL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75160-3115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-563-3311
-----------------------------------------------------
Fax | 972-563-5808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 W MOORE AVE
-----------------------------------------------------
City | TERRELL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75160-3115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-563-3311
-----------------------------------------------------
Fax | 972-563-5808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. FRED BENTLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-563-3311
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 5059140001
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------