Provider Demographics
NPI:1386729523
Name:BENNETT, MARTY JEANNE (DPH)
Entity type:Individual
Prefix:MS
First Name:MARTY
Middle Name:JEANNE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 MOW-WAY ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503
Mailing Address - Country:US
Mailing Address - Phone:580-458-2300
Mailing Address - Fax:580-458-2445
Practice Address - Street 1:4301 MOW-WAY ROAD
Practice Address - Street 2:REYNOLDS ARMY COMMUNITY HOSPITAL (ATTN:MS.PRESCOTT)
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-6300
Practice Address - Country:US
Practice Address - Phone:580-458-2134
Practice Address - Fax:580-458-2314
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11231183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK11231OtherPHARMACY LIC #