MEDICARE: MRS. IDALIA BONILLA LCDA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	3736	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3736	OTHER	PR	PHARMACIST LICENSE

General Provider Information

NPI Number	:	1043296387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. IDALIA BONILLA LCDA

Provider Business Mailing Address
First Line	:	PO BOX 1542
Second Line	:
City	:	VILLALBA
State	:	PR
Zip	:	00766-1542
Country	:	US
Telephone Number	:	787-847-8600
Fax Number	:	787-847-3336

Provider Business Practice Location Address
First Line	:	CARR 149 KM 58.1BARRIO TIERRA SANTA
Second Line	:
City	:	VILLALBA
State	:	PR
Zip	:	00766
Country	:	US
Telephone Number	:	787-847-8600
Fax Number	:	787-847-3336

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	07/08/2007

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