Healthcare Provider Details

I. General information

NPI: 1215342639
Provider Name (Legal Business Name): BONNE SANTE COMPOUNDING PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36700 WOODWARD AVE SUITE 105
BLOOMFIELD HILLS MI
48304-0926
US

IV. Provider business mailing address

36700 WOODWARD AVE SUITE 105
BLOOMFIELD HILLS MI
48304-0926
US

V. Phone/Fax

Practice location:
  • Phone: 249-792-2920
  • Fax: 248-792-2865
Mailing address:
  • Phone: 249-792-2920
  • Fax: 248-792-2865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010444
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2146643
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: KSHAMA JAYASURIYA
Title or Position: R.PH
Credential:
Phone: 248-792-2920