Provider Demographics
NPI:1619953122
Name:BONDURANT, MARK AARON (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:AARON
Last Name:BONDURANT
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 1:25 PARK RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45419-3002
Mailing Address - Country:US
Mailing Address - Phone:937-294-2439
Mailing Address - Fax:937-428-7978
Practice Address - Street 1:2601 S SMITHVILLE RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-2641
Practice Address - Country:US
Practice Address - Phone:937-253-3166
Practice Address - Fax:937-253-3165
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-13193183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0477041Medicaid
OH3638422OtherNABP #
OH3638422OtherNABP #