Provider Demographics
NPI:1013673979
Name:BONHAM, JILL DIANE
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:DIANE
Last Name:BONHAM
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 1:3061 KINGSDALE CTR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-2009
Mailing Address - Country:US
Mailing Address - Phone:614-538-0801
Mailing Address - Fax:614-538-0825
Practice Address - Street 1:3061 KINGSDALE CTR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-2009
Practice Address - Country:US
Practice Address - Phone:614-538-0801
Practice Address - Fax:614-538-0825
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03120493183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist