Provider Demographics
NPI:1639277056
Name:THOM, BONNIE JEAN
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:JEAN
Last Name:THOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:VELVA
Mailing Address - State:ND
Mailing Address - Zip Code:58790-0010
Mailing Address - Country:US
Mailing Address - Phone:701-338-2911
Mailing Address - Fax:701-338-2886
Practice Address - Street 1:16 N MAIN
Practice Address - Street 2:
Practice Address - City:VELVA
Practice Address - State:ND
Practice Address - Zip Code:58790-0010
Practice Address - Country:US
Practice Address - Phone:701-338-2911
Practice Address - Fax:701-338-2886
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3416183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist