Provider Demographics
NPI:1487830576
Name:BONITATIBUS, CORINE M (RPH)
Entity Type:Individual
Prefix:MS
First Name:CORINE
Middle Name:M
Last Name:BONITATIBUS
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 1:1170 WESTERN AVE.
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-3314
Mailing Address - Country:US
Mailing Address - Phone:518-459-0795
Mailing Address - Fax:518-459-0737
Practice Address - Street 1:1170 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3314
Practice Address - Country:US
Practice Address - Phone:518-459-0795
Practice Address - Fax:518-459-0737
Is Sole Proprietor?:No
Enumeration Date:2008-01-18
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047512183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist