Provider Demographics
NPI:1497752174
Name:BONIFAS, JESSICA R (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:R
Last Name:BONIFAS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 MARKETPLACE DR
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1548
Mailing Address - Country:US
Mailing Address - Phone:952-442-4407
Mailing Address - Fax:952-442-5787
Practice Address - Street 1:851 MARKETPLACE DR
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1548
Practice Address - Country:US
Practice Address - Phone:952-442-4407
Practice Address - Fax:952-442-5787
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2010-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118050-5183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist