Provider Demographics
NPI:1043500838
Name:BOMIA, MARK
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:BOMIA
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 1:31700 VAN DYKE AVE
Mailing Address - Street 2:SUITE 190
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-7949
Mailing Address - Country:US
Mailing Address - Phone:586-276-8040
Mailing Address - Fax:586-276-8039
Practice Address - Street 1:31700 VAN DYKE AVE
Practice Address - Street 2:SUITE 190
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-7949
Practice Address - Country:US
Practice Address - Phone:586-276-8040
Practice Address - Fax:586-276-8039
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025030183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist