Provider Demographics
NPI:1649495466
Name:DOUGLASS, BONNIE CARLA (CHPHT)
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:CARLA
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:CHPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-5449
Mailing Address - Country:US
Mailing Address - Phone:352-688-9226
Mailing Address - Fax:
Practice Address - Street 1:14134 US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-1167
Practice Address - Country:US
Practice Address - Phone:727-869-3114
Practice Address - Fax:727-861-2412
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3901-0107-0258-142183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0556050370Medicare ID - Type Unspecified
FL1074145Medicare UPIN