=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760503874
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTIAN GOSWIN BONNER PHARM.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 06/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26 MADDEX SQUARE DR
-----------------------------------------------------
City | SHEPHERDSTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25443-4321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-876-0505
-----------------------------------------------------
Fax | 304-876-8412
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 324 E ANTIETAM ST
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21740-5754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-766-4167
-----------------------------------------------------
Fax | 301-745-4164
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP439808
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | WV6243
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 020212955
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 15461
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------