Provider Demographics
NPI:1316148372
Name:SLADE, BONNIE (CPHT)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:SLADE
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11441 126TH TER
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-1916
Mailing Address - Country:US
Mailing Address - Phone:727-798-1395
Mailing Address - Fax:
Practice Address - Street 1:10000 BAY PINES BLVD
Practice Address - Street 2:DEPT OF VETERANS AFFAIRS MEDICAL CENTER
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33744-9900
Practice Address - Country:US
Practice Address - Phone:727-398-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3201-0105-0761-105183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician