Provider Demographics
NPI:1700968641
Name:BONFIGLIO DRUG, INC
Entity Type:Organization
Organization Name:BONFIGLIO DRUG, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:BONFIGLIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-736-2377
Mailing Address - Street 1:PO BOX 748
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:CO
Mailing Address - Zip Code:80467-0748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:CO
Practice Address - Zip Code:80467
Practice Address - Country:US
Practice Address - Phone:970-736-2377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO94-013336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0605444OtherNCPDP
CO03002532Medicaid
4869130001Medicare ID - Type Unspecified