Healthcare Provider Details

I. General information

NPI: 1497752174
Provider Name (Legal Business Name): JESSICA R BONIFAS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 MARKETPLACE DR
WACONIA MN
55387-1548
US

IV. Provider business mailing address

851 MARKETPLACE DR
WACONIA MN
55387-1548
US

V. Phone/Fax

Practice location:
  • Phone: 952-442-4407
  • Fax: 952-442-5787
Mailing address:
  • Phone: 952-442-4407
  • Fax: 952-442-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number118050-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: