Provider Demographics
NPI:1902963648
Name:BENNETT'S HOMETOWN PHARMACY, LLC
Entity Type:Organization
Organization Name:BENNETT'S HOMETOWN PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:912-462-3784
Mailing Address - Street 1:13202 CLEVELAND ST W STE 100
Mailing Address - Street 2:
Mailing Address - City:NAHUNTA
Mailing Address - State:GA
Mailing Address - Zip Code:31553-2842
Mailing Address - Country:US
Mailing Address - Phone:912-462-3784
Mailing Address - Fax:912-462-8040
Practice Address - Street 1:13202 CLEVELAND ST W STE 100
Practice Address - Street 2:
Practice Address - City:NAHUNTA
Practice Address - State:GA
Practice Address - Zip Code:31553-2842
Practice Address - Country:US
Practice Address - Phone:912-462-3784
Practice Address - Fax:912-462-8040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
GAPHRE0088783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA735642371BMedicaid
GA735642371AMedicaid
GA735642371BMedicaid