Provider Demographics
NPI:1386988160
Name:JEFFREY A BONJO
Entity type:Organization
Organization Name:JEFFREY A BONJO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BONJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-571-0770
Mailing Address - Street 1:310 S MAIN ST STE K
Mailing Address - Street 2:
Mailing Address - City:YEAGERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17099-9709
Mailing Address - Country:US
Mailing Address - Phone:717-953-9534
Mailing Address - Fax:717-953-9536
Practice Address - Street 1:310 S MAIN ST STE K
Practice Address - Street 2:
Practice Address - City:YEAGERTOWN
Practice Address - State:PA
Practice Address - Zip Code:17099-9709
Practice Address - Country:US
Practice Address - Phone:717-953-9534
Practice Address - Fax:717-953-9536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-19
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4822083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135249OtherPK
PA102778068Medicaid