Provider Demographics
NPI:1164417770
Name:BONHAM, MICHAEL J (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:BONHAM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 SUNSET CT
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2640
Mailing Address - Country:US
Mailing Address - Phone:309-266-7202
Mailing Address - Fax:
Practice Address - Street 1:8800 RT 91 N
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615
Practice Address - Country:US
Practice Address - Phone:309-683-4723
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy