Provider Demographics
NPI:1255484523
Name:BONACCORSI, STEPHEN JOSEPH
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:JOSEPH
Last Name:BONACCORSI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PITMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08071-1413
Mailing Address - Country:US
Mailing Address - Phone:856-589-2392
Mailing Address - Fax:856-589-5206
Practice Address - Street 1:39 S BROADWAY
Practice Address - Street 2:
Practice Address - City:PITMAN
Practice Address - State:NJ
Practice Address - Zip Code:08071-1413
Practice Address - Country:US
Practice Address - Phone:856-589-2392
Practice Address - Fax:856-589-5206
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01596400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist