Provider Demographics
NPI:1780027680
Name:BONISTALLI, MICHELE C (RPH)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:C
Last Name:BONISTALLI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 WATKINS MILL RD
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-3301
Mailing Address - Country:US
Mailing Address - Phone:240-632-4150
Mailing Address - Fax:240-632-4151
Practice Address - Street 1:655 WATKINS MILL RD
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3301
Practice Address - Country:US
Practice Address - Phone:240-632-4150
Practice Address - Fax:240-632-4151
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11261183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist