Provider Demographics
NPI:1093850877
Name:BONNER PROFESSIONAL COMPOUNDING
Entity Type:Organization
Organization Name:BONNER PROFESSIONAL COMPOUNDING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:RICKARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-263-1441
Mailing Address - Street 1:520 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1507
Mailing Address - Country:US
Mailing Address - Phone:208-265-1093
Mailing Address - Fax:208-265-1031
Practice Address - Street 1:520 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1507
Practice Address - Country:US
Practice Address - Phone:208-265-1093
Practice Address - Fax:208-265-1031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1402CP1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1402CPOtherSTATE BOARD OF PHARMACY
DCBB8651526OtherCONTROLLED SUBSTANCE REGI