Provider Demographics
NPI:1790962785
Name:DECASTRO, BONNY (RPH)
Entity Type:Individual
Prefix:
First Name:BONNY
Middle Name:
Last Name:DECASTRO
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 1:6 KENDALL WAY
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-4399
Mailing Address - Country:US
Mailing Address - Phone:518-899-0076
Mailing Address - Fax:518-899-1134
Practice Address - Street 1:6 KENDALL WAY
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-4399
Practice Address - Country:US
Practice Address - Phone:518-899-0076
Practice Address - Fax:518-899-1134
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042841183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist