Provider Demographics
NPI:1164007712
Name:BONIN, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BONIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51450 SHELBY PKWY
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-1786
Mailing Address - Country:US
Mailing Address - Phone:586-997-6905
Mailing Address - Fax:
Practice Address - Street 1:16015 MOORE PARK RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-1148
Practice Address - Country:US
Practice Address - Phone:586-994-1559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist