MEDICARE: RYAN BONOMO RPH

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	26019301A	IN

General Provider Information

NPI Number	:	1154664217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN BONOMO RPH

Provider Business Mailing Address
First Line	:	1300 WABASH AVE
Second Line	:
City	:	TERRE HAUTE
State	:	IN
Zip	:	47807-3314
Country	:	US
Telephone Number	:	812-234-5147
Fax Number	:	812-232-1274

Provider Business Practice Location Address
First Line	:	1300 WABASH AVE
Second Line	:
City	:	TERRE HAUTE
State	:	IN
Zip	:	47807-3314
Country	:	US
Telephone Number	:	812-234-5147
Fax Number	:	812-232-1274

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

Provider Enumeration Date	:	03/27/2013
Last Update Date	:	03/27/2013

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Directions to “ RYAN BONOMO RPH” Practice Location

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