Provider Demographics
NPI:1053693028
Name:BENNIN, ALFRED (RPH)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:
Last Name:BENNIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 US HWY 51/138
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589
Mailing Address - Country:US
Mailing Address - Phone:608-873-7612
Mailing Address - Fax:
Practice Address - Street 1:1705 US HWY 51/138
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589
Practice Address - Country:US
Practice Address - Phone:608-873-7612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7481-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7481-40OtherLICENSED PHARMACIST