Provider Demographics
NPI:1578156220
Name:BONAOBRA, JOHN RYAN
Entity Type:Individual
Prefix:
First Name:JOHN RYAN
Middle Name:
Last Name:BONAOBRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 S ELM PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-6453
Mailing Address - Country:US
Mailing Address - Phone:918-258-6185
Mailing Address - Fax:
Practice Address - Street 1:1770 S ELM PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-6453
Practice Address - Country:US
Practice Address - Phone:918-258-6185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-13
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26021183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician