Provider Demographics
NPI:1083728406
Name:NOBLET, BONNIE GALE (RPH)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:GALE
Last Name:NOBLET
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10112 YAWBERG RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:OH
Mailing Address - Zip Code:43522-9614
Mailing Address - Country:US
Mailing Address - Phone:419-832-8335
Mailing Address - Fax:419-832-0601
Practice Address - Street 1:24187 FRONT ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:OH
Practice Address - Zip Code:43522-9410
Practice Address - Country:US
Practice Address - Phone:419-832-4615
Practice Address - Fax:419-832-0601
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03310362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2044979Medicaid
OH2044979Medicaid