Provider Demographics
NPI:1336289719
Name:JACQUE, BONITA (RPH)
Entity Type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:
Last Name:JACQUE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13377 WOODLAND CT
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-9448
Mailing Address - Country:US
Mailing Address - Phone:231-796-3871
Mailing Address - Fax:231-796-3879
Practice Address - Street 1:1250 PERRY AVE
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2115
Practice Address - Country:US
Practice Address - Phone:231-796-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023883183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist