Provider Demographics
NPI:1730286576
Name:BONITA PHARMACY INC
Entity Type:Organization
Organization Name:BONITA PHARMACY INC
Other - Org Name:BONITA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHRG
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:YEP
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:619-475-4112
Mailing Address - Street 1:4190 BONITA RD
Mailing Address - Street 2:STE 101
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1329
Mailing Address - Country:US
Mailing Address - Phone:619-475-4112
Mailing Address - Fax:619-475-4113
Practice Address - Street 1:4190 BONITA RD
Practice Address - Street 2:STE 101
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-1329
Practice Address - Country:US
Practice Address - Phone:619-475-4112
Practice Address - Fax:619-475-4113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY216033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0529428OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA216030Medicaid
0529428OtherNCPDP PROVIDER IDENTIFICATION NUMBER