Provider Demographics
NPI:1710008198
Name:GLENN R BONIFIELD JR
Entity Type:Organization
Organization Name:GLENN R BONIFIELD JR
Other - Org Name:MEHR DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:BONIFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:731-663-2077
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:BELLS
Mailing Address - State:TN
Mailing Address - Zip Code:38006-0280
Mailing Address - Country:US
Mailing Address - Phone:731-663-2077
Mailing Address - Fax:731-663-2077
Practice Address - Street 1:131 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLS
Practice Address - State:TN
Practice Address - Zip Code:38006-4167
Practice Address - Country:US
Practice Address - Phone:731-663-2077
Practice Address - Fax:731-663-2077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN000001203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2095063OtherPK
5555000001Medicare NSC