Provider Demographics
NPI:1588427033
Name:BONKOWSKI, BLAKE (PHARMD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:BONKOWSKI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4363 S 4 MILE RD
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-9254
Mailing Address - Country:US
Mailing Address - Phone:989-277-1924
Mailing Address - Fax:
Practice Address - Street 1:2350 3 MILE RD NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-1305
Practice Address - Country:US
Practice Address - Phone:989-277-1924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039879183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist