Provider Demographics
NPI:1194177592
Name:BENNETT, MARY THERESA (RPH)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:THERESA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10753 GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:COOPERSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49404-9741
Mailing Address - Country:US
Mailing Address - Phone:616-617-8643
Mailing Address - Fax:
Practice Address - Street 1:924 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1419
Practice Address - Country:US
Practice Address - Phone:231-924-3790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030215183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist