Provider Demographics
NPI:1063795391
Name:DIMAYACYAC, BONIFACIO G
Entity type:Individual
Prefix:
First Name:BONIFACIO
Middle Name:G
Last Name:DIMAYACYAC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17758 CAPE JASMINE RD
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91387-3817
Mailing Address - Country:US
Mailing Address - Phone:661-347-3567
Mailing Address - Fax:
Practice Address - Street 1:1834 W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2745
Practice Address - Country:US
Practice Address - Phone:661-723-0363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63837183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist