Healthcare Provider Details

I. General information

NPI: 1295824274
Provider Name (Legal Business Name): BONNIE J MARTY PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 MIRANDA AVE PHARMACY DEPARTMENT - MAIL CODE 119
PALO ALTO CA
94304-1207
US

IV. Provider business mailing address

123 KESTREL CT
BRISBANE CA
94005-1231
US

V. Phone/Fax

Practice location:
  • Phone: 650-493-5000
  • Fax: 650-849-0309
Mailing address:
  • Phone: 415-468-5447
  • Fax: 650-849-0309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number41670
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: