Provider Demographics
NPI:1164587580
Name:BONNEVILLE RX LLC
Entity Type:Organization
Organization Name:BONNEVILLE RX LLC
Other - Org Name:BONNEVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RAVINDER
Authorized Official - Middle Name:
Authorized Official - Last Name:ANNAMANENI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-774-9362
Mailing Address - Street 1:77 WESTCOTT RD
Mailing Address - Street 2:
Mailing Address - City:DANIELSON
Mailing Address - State:CT
Mailing Address - Zip Code:06239-2929
Mailing Address - Country:US
Mailing Address - Phone:860-774-9362
Mailing Address - Fax:860-779-2647
Practice Address - Street 1:77 WESTCOTT RD
Practice Address - Street 2:
Practice Address - City:DANIELSON
Practice Address - State:CT
Practice Address - Zip Code:06239-2929
Practice Address - Country:US
Practice Address - Phone:860-774-9362
Practice Address - Fax:860-779-2647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCY00001593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138266OtherPK