=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598124588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BONITA DRIVE THRU PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2016
-----------------------------------------------------
Last Update Date | 11/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4190 BONITA RD STE 101
-----------------------------------------------------
City | BONITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91902-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-900-6002
-----------------------------------------------------
Fax | 619-900-6012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4190 BONITA RD STE 101
-----------------------------------------------------
City | BONITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91902-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-900-6002
-----------------------------------------------------
Fax | 619-900-6012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | DANIEL LEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-434-5350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 53888
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------