Provider Demographics
NPI:1023181989
Name:BOHL, BONITA SIMCHA (R PH)
Entity Type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:SIMCHA
Last Name:BOHL
Suffix:
Gender:F
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 LAKE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-4605
Mailing Address - Country:US
Mailing Address - Phone:248-645-0375
Mailing Address - Fax:
Practice Address - Street 1:21298 MELROSE AVENUE
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-7901
Practice Address - Country:US
Practice Address - Phone:248-827-3370
Practice Address - Fax:248-827-3375
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302025029OtherPHARMACY LICENSE