Provider Demographics
NPI:1528168952
Name:BENNETT, MARK DAVID
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 VALLEYBROOK ROAD
Mailing Address - Street 2:
Mailing Address - City:BOYERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19512
Mailing Address - Country:US
Mailing Address - Phone:610-473-0859
Mailing Address - Fax:610-473-0859
Practice Address - Street 1:206 NORTH CHARLOTTE STREET
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464
Practice Address - Country:US
Practice Address - Phone:610-326-9690
Practice Address - Fax:610-326-9723
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP044103L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist