Provider Demographics
NPI:1609282680
Name:BONNELL, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BONNELL
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 1:926 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WARTBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37887-4199
Mailing Address - Country:US
Mailing Address - Phone:423-346-3505
Mailing Address - Fax:423-346-5105
Practice Address - Street 1:926 MAIN ST
Practice Address - Street 2:
Practice Address - City:WARTBURG
Practice Address - State:TN
Practice Address - Zip Code:37887-4199
Practice Address - Country:US
Practice Address - Phone:423-346-3505
Practice Address - Fax:423-346-5105
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38341183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist