Provider Demographics
NPI:1417639014
Name:BONILLA, JOSE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:BONILLA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 SIMPSON RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4675
Mailing Address - Country:US
Mailing Address - Phone:407-348-7686
Mailing Address - Fax:
Practice Address - Street 1:2625 SIMPSON RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4675
Practice Address - Country:US
Practice Address - Phone:407-348-7686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS65871183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist