Provider Demographics
NPI:1326788928
Name:JOHNSON, BONITA MICHELE
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:MICHELE
Last Name:JOHNSON
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 1:1415 CROSSINGS CENTRE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551
Mailing Address - Country:US
Mailing Address - Phone:434-534-3350
Mailing Address - Fax:434-534-3352
Practice Address - Street 1:1415 CROSSINGS CENTRE DR
Practice Address - Street 2:SUITE A
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551
Practice Address - Country:US
Practice Address - Phone:434-534-3350
Practice Address - Fax:434-534-3352
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009862183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist