Provider Demographics
NPI:1508090747
Name:BODENSTEINER, JOHN JOSEPH (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JOSEPH
Last Name:BODENSTEINER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16979 E 2705 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61834-6059
Mailing Address - Country:US
Mailing Address - Phone:217-759-7465
Mailing Address - Fax:
Practice Address - Street 1:311 W FAIRCHILD ST
Practice Address - Street 2:SUITE B
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3876
Practice Address - Country:US
Practice Address - Phone:217-431-7759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-02
Last Update Date:2009-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.029707183500000X
IN26012728A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist