Provider Demographics
NPI:1457448318
Name:BONNER DISCOUNT DRUGS
Entity Type:Organization
Organization Name:BONNER DISCOUNT DRUGS
Other - Org Name:BONNER DISCOUNT DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-735-2141
Mailing Address - Street 1:1017 HIGHWAY 84 E
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:MS
Mailing Address - Zip Code:39367-2632
Mailing Address - Country:US
Mailing Address - Phone:601-735-2141
Mailing Address - Fax:601-735-2141
Practice Address - Street 1:1017 HIGHWAY 84 E
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-2632
Practice Address - Country:US
Practice Address - Phone:601-735-2141
Practice Address - Fax:601-735-2141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS015693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2044342OtherPK
MS0095028Medicaid