Provider Demographics
NPI:1114198280
Name:HART, BONNIE JEAN (BS IN PHARMACY)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:JEAN
Last Name:HART
Suffix:
Gender:F
Credentials:BS IN PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8222 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-2901
Mailing Address - Country:US
Mailing Address - Phone:718-256-6636
Mailing Address - Fax:
Practice Address - Street 1:8222 18TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-2901
Practice Address - Country:US
Practice Address - Phone:718-256-6636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044566183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00908030Medicaid