Provider Demographics
NPI:1417052937
Name:JEFFREY RYAN BENNETT
Entity type:Organization
Organization Name:JEFFREY RYAN BENNETT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-464-7722
Mailing Address - Street 1:2005 S MARIPOSA RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-7735
Mailing Address - Country:US
Mailing Address - Phone:209-464-7722
Mailing Address - Fax:209-464-7404
Practice Address - Street 1:2005 S MARIPOSA RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-7735
Practice Address - Country:US
Practice Address - Phone:209-464-7722
Practice Address - Fax:209-464-7404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417052937Medicaid
CAPHY59418OtherCALIFORNIA STATE BOARD OF PHARMACY
0510239OtherNABP