Provider Demographics
NPI:1043296387
Name:BONILLA, IDALIA (LCDA)
Entity Type:Individual
Prefix:MRS
First Name:IDALIA
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:LCDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1542
Mailing Address - Street 2:
Mailing Address - City:VILLALBA
Mailing Address - State:PR
Mailing Address - Zip Code:00766-1542
Mailing Address - Country:US
Mailing Address - Phone:787-847-8600
Mailing Address - Fax:787-847-3336
Practice Address - Street 1:CARR 149 KM 58.1BARRIO TIERRA SANTA
Practice Address - Street 2:
Practice Address - City:VILLALBA
Practice Address - State:PR
Practice Address - Zip Code:00766
Practice Address - Country:US
Practice Address - Phone:787-847-8600
Practice Address - Fax:787-847-3336
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3736183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3736OtherPHARMACIST LICENSE